A Need for Accountability

“It’s hard to be credible after preaching accountability but failing to deal with performance issues and poor performers.”
- Art Petty

The administrator of a mid-sized practice had been asked by the owners to focus on quality: quality related to patient satisfaction and care, employee satisfaction and care, and provider quality as well. Part of the program included administering patient satisfaction questionnaires at a rate of two surveys per day per provider. This frequency provided for excellent statistics as well as a higher level of awareness for the management team. The online survey process let him know, within minutes of survey submission, when they had a disgruntled patient.

The administrator provided motivational talks to his management team, but the survey frequency remained at less than 10% of the goal of 2 surveys per day per provider. He did some research and found that the paper surveys took only two minutes to enter into the system. With 20 providers that meant 80 minutes per day needed to be dedicated to survey entry, assuming surveys weren’t being done on the kiosks which took, essentially, no staff time. He also learned, from some MGMA data, that his appointments/phone team averaged 90 minutes per day of free time. The receptionist team members averaged over an hour of free time per day. So, he knew the team had time available.

He asked the front office manager to watch receptionist behavior during the checkout process. The receptionists were scheduling follow-on appointments and other administrative items. They also were providing a paper version of the patient survey by attaching it to the back of the paperwork with no explanation. This was an issue, not proactive, and very likely a contributor to the low survey rates.

With this information in hand, he suggested that the receptionists should ask something like, “Mrs. Jones, we appreciate that you come to us for your medical needs. Will you provide us just a couple of minutes of your time to give us some feedback? This feedback will be used to improve your experience the next time you visit and maintain the quality care we provide for all patients.” He told them that if Mrs. Jones says she can’t complete a survey on the spot, the receptionist should provide a paper survey with a postage paid envelope and ask her if she’ll take the time at home and mail it in.

For three days his practice hit the numbers…

• 40 or more surveys, per day, were submitted.
• He received 5-10 alerts every day, letting him know when patients were answering a Strongly Disagree or Disagree on their surveys.
• His awareness was elevated; he dealt with issues immediately, and the team members received feedback.
• That Friday he received another email alert that provided all of the patient kudos for the previous 7 calendar days. There were over 100 comments about staff members who were particularly helpful.
• This, in turn, provided the data he needed to properly recognize the team, something that had been highlighted as an issue in the past.

The next week the surveys continued to come in, but at half the desired rate. A week later, the surveys had, more or less, stopped.

The administrator went through this cycle repeatedly, providing encouragement to his staff several times over the following months. Every time he did it the survey frequency hit acceptable levels for about a week and then died off. Getting the staff to obtain an acceptable number of completed surveys each day over a period longer than a week was like keeping several plates spinning on sticks in mid-air. A friend of mine from our days teaching at the U.S. Air Force Academy used to say, “You can lead a horse to water. You can’t make it drink. But, you can make it wish it had.” I share this quote because a lack of accountability is hurting so many organizations. They are less effective. Staff is dissatisfied. Quality is falling far short of the organization’s potential.

From working with many organizations, we can confirm an enormous shortfall when it comes to organizational accountability. Without exception–yes, 100% of the time–we find management teams are NOT holding their workers to task on what we see as reasonable expectations. It seems to be a sign of the times… we don’t want to offend ANYONE. We don’t clearly define expectations. We over-accommodate, but by attempting to make this “work thing” non-offensive we also inadvertently make it less productive.

“A duty dodged is like a debt unpaid; it is only deferred, and we must come back and settle the account at last.”
- Joseph Fort Newton

We understand the need to create a sharing and compassionate work environment. However, we are all running businesses, and we expect people to contribute. Here are some recommendations:

1. If you don’t have a review system in place, create one now. Include specific expectations for the review period. Clearly explain the acceptable minimums and the consequences of failing to meet them. Use real science/survey results whenever possible.

2. If you don’t have a bonus program, consider it. If the organization makes an additional $2 for every $1 you pay out in a bonus pool, why wouldn’t you do this? Bonuses should be computed based upon what the individual can truly influence. Bottom line can be influenced by everyone. Safety numbers are affected by all. Patient satisfaction can be affected by all. This is definitely something to consider.

3. People need continuous feedback. No one should ever be surprised when they receive their review. Mid-course corrections are critical. Monthly interactions are recommended.

This week, according to BusinessWeek, AIG (American International Group, Inc.) announced an overhauled incentive pay system. About 10% of the workers will be placed in the top rank, getting the biggest bonuses. 70% will fall in the middle tiers. The bottom 20% of performers will get the lowest payouts. Christina Pretto, an AIG spokeswoman, said, “We recently launched a performance management initiative that aims to bring greater alignment between an individual’s performance and compensation. These ratings will help ensure that our people are accountable, recognized and rewarded for their achievements.”

In the past year we’ve worked with several groups, from very large to very small, that had no performance review system, no job descriptions and very little accountability in place. Because of the economy and the “new normal,” these organizations had no choice but to reevaluate their models. When we ran a “survey of environment” it was very clear the teams were dissatisfied. Specific areas like communication, recognition, coaching and accountability were typically below the national benchmark. As recently as a week ago, each of the organizations had low performers who were dragging the rest of their team members down. Survey comments confirmed a high level of frustration across the team: “Why do I have to carry the load for the slackers?” “Enough of the favoritism, will someone please eliminate the non-producers?” and so on…

Many of you are aware of our model; we share it openly.

1. Reflect: Decide whether you want to improve. This isn’t a joke; many don’t care to improve. They don’t want the boat rocked. They are close to retirement and just want to leave the organization “as is.” If you want to improve, you’ll need to change something. You’ve heard Einstein’s quote, “Insanity is doing the same thing over and over again and expecting different results.” Invest the time to evaluate and reinvent. The return on investment will be impressive.

2. Observe: Run the surveys; get the science. We have gathered so many humorous quotes! “We run a survey every couple years to fill the square.” “We’re busy enough as it is; no time to ask our customers for input,” and so on. Use an online survey; it will be simple, inexpensive and full of valuable information. Increase your level of awareness; allow your customers/patients to provide input; allow your employees to evaluate the environment and to be part of the process. The best way to get your employees to pick up the trash littering the front entry is by inducing them to care. In order for them to care they need to feel ownership. It doesn’t have to be in the form of stock! As long as they feel emotional ownership, believe they are part of a great team, and are asked for input they will behave as contributing members and not just employees working for a paycheck.

3. Improve: Our experience shows that only a small fraction of organizations take the time to do what we call a reinvention exercise. Where have we been? How did we do? Where do we want to be? How are we going to get there? It doesn’t have to be complicated. Just last week I met with a medical group for a half-day reinvention exercise. In fact, we started at 8:30 a.m. and were out the door by 2 p.m. In that time we:
     a. Reviewed the survey data. Internal and external science provided the perspective we needed to identify issues.
     b. Divided into task forces. Each group worked two hours using the survey data and driving to a list of just a few SMART goals for the year.
     c. Listened to task force presentations of just a few minutes each, so the organization could agree on the recommendations. Consensus is critical. With all task force action items approved, the group walked out the door with a list of action items that directly addressed the issues highlighted in the survey data.
     d. Then it was back to the regular tasks, executing with quarterly accountability for three quarters and then administering another round of surveys and setting up the next annual reinvention.

4. In times past, we could put together a 5-year plan and get to year two, perhaps, before needing to redo the plan. These days, more frequent reinvention is necessary. It’s also important to consider the amount of “noise” we need to mute. In today’s economic environment there are huge changes on the horizon; health care is a great example. Can you have a significant effect on the outcome? Probably not. So, compartmentalize those issues for offline discussions. The most productive reinventions look at the things the organization can truly affect; they come down to customer/patient care, employee satisfaction and owner/provider satisfaction.

“It is easy to dodge our responsibilities, but we cannot dodge the consequences of dodging our responsibilities.”
-  Sir Josiah Stamp

Not many readers will make it to this part of the article. They will have been interrupted by something urgent, a walk-in employee, an email or a phone call. They live in the world of urgent. They don’t take the time to reflect on their priorities. How about you? Have you scheduled 15 minutes, every morning, to focus on your list of priorities? Have you even derived a list of personal and professional priorities?

Life is short, but you have time to change. Your team needs you to change, to be proactive, to incorporate the fundamentals of effective leadership. So, get with it!