More from the Maxwell presentation at MGMA and a Lean Belt

John Maxwell's Speech at MGMA

I was intrigued by the themes and concepts that John Maxwell espoused during his presentation. His key points have been a part of what we talk about when we look at the MGMA Lean Six Sigma Belt program. Those points were:

Culture – in order to change, to grow, to eliminate inefficiencies, and to improve patient care your culture must focus on or allow changes to achieve these outcomes. It is essential that you understand your culture – this is not expressed just in words in a mission or value statement but more likely in deeds. Stating your values around quality care, respect, etc. is not the true culture. It is what occurs, activities, tasks and daily words used that creates and defines your culture. Take a serious look at yours.

Value – we talk about Lean principles are built on the concept of adding value to the customer. Value-add activities and tasks built into your culture will lead your business to be successful. Eliminate non-value add activities! Imagine if you made an effort to add value to someone or something every day and this attitude became pervasive throughout your business.

Rule of 5 – in Lean programs we talk about the FIVE whys. A great set of questions about why you or one of your fellow employees is doing something or doing it in a certain way. You can always improve by asking your self why. Slightly different is the Maxwell rule of 5 but it built on the same principle. Work to improve daily, and focus on five steps or ways that you can improve. Do it daily.

Finally, Maxwell talked about the importance of working together as a team. Work in a positive culture that encourages growth, that allows you individually to grow and at the same time improve the outcomes of your team.

It was amazing to hear him talk about so many of the keys that we identify in our belt programs!

Maxwell at MGMA in Vegas

John Maxwell the leading expert on “Leadership” was the Monday morning keynote and what a great presentation. It was build around his 15 Invaluable Laws of Leadership.

One of his laws it that of INTENTIONALITY. Growth doesn’t just happen! We often talk about our experiences as part of our growth. Do you have twenty years of experience or one year of experience 20 times? You don’t automatically grow; it is a process an effort. The best teaching part of our experience though is the evaluation; do we stop to evaluate our experiences as we grow? We should.

When you wake up in the morning challenge yourself with a simple concept, whom am I going to add value to today! This will set a framework of a positive attitude.

Another key law is that of CONSISTENCY, which he highlighted as a boring concept. You always want to hear how good you are from other, hearing you being defined as consistent is one of your best compliments. Motivation gets you going but discipline gets you growing!

He has a rule of five citing a story of chopping a tree with an axe five swings today. Five swings tomorrow, the next and the next. This is to say that there are five things that you should do everyday related to your purpose. These five things will provide you with a focused result, success. They will also lead you to be consistent in your daily life. As an author his rule of five for each day is: read; think; file, ask questions; and write which he does each and every day including holidays and vacation days.

His final rule covered in the presentation was the rule of ENVIRONMENT – your surroundings must be conducive to growth. People are your most appreciable asset, what are you doing to grow them in your work place.

Consistent from what we heard from Lou Holtz – attitude, focus on the now, and grow. What a great set of principles and concepts from both. I hope my sharing this with you spreads the word and encourages you to identify your attitude, live in the now and consistently strive to grow. This will make you a better person and have a positive impact and all you come in contact with.

Lou Holtz and MGMA

At the MGMA Annual Conference, AC, Lou Holtz the hall of fame Football coach of schools such as Arkansas, Notre Dame, and South Carolina gave the Opening Key Note address. What a great presentation.

He talked about a five-part plan built around the idea that “titles are from above, leaders are from below!” What a concept!

His five-part plan:

• Attitude – have fun and add value to your self and your practice.
• Passion to succeed – to win in his world, your definition of success is yours but you must have a passion for it.
• Focus on your purpose – we are individuals but in the world we are a team, one that needs each other to achieve our purpose.
• Make sure you are growing and not dying, we need something to hope for.
• Make good choices, help your children make good choices (your fellow employees make good choices).

His acronym here was to WIN – what this stands for is

• What’s
• Important
• Now

His three rules:

• Do what’s right
• Do everything to the best of your ability
• Show people you care

Throughout his presentation he offered stories to support each of these key points – awesome for an 83 year old who was up and on TV until 3 AM Eastern time and spoke to us at 3 PM Pacific time!

Above all – in the football vernacular – do not attack the performer, attack the performance!

Very glad to have had the opportunity to hear him!

Passive Aggressive Physician Responses in the Medical Practice

A lot of comments lately on the fact that the doctor does not want to change, they don’t feel the “pain” or accept a reason for change. More importantly, we hear that the administration brings up an issue at the monthly board meeting. There is discussion about the issue and eventually there is a vote or consensus reached that the recommendation for change it accepted.

The next day however, the doctor does not change to the new way. Instead indicates that the decision does not apply to them, it is for others. Or I’m about to retire and I don’t have to change. Or I don’t like someone telling me how to run my practice.

So passive response = yes to the vote followed by aggressive = no I won’t change is the result. In my years, this is a very common situation.

How do you deal with it? A recent article in Psychology Today offers some suggestions:

• Don’t over react when you find out about the response, this may lead to even more of that behavior 
• Don’t force the change 
• Proactively deal with the situation 
• Get the doctor involved with what might work in their specific practice. Work with the supportive staff to help. Identify the problem and seek a solution that will work. 
• There may have to be direct consequences for the lack of acceptance of the change. This can be accomplished with peer pressure, e.g., comments at the next doctor meeting. It may also be accomplished by some form of monetary penalty if there is a tie to the lack of change in behavior to some risk to the practice. 

How does this fit in with the purpose of this blog? If you believe that improvements in care are necessary, there will have to be changes made. These changes will impact the physician practice directly. Even though many changes can and will be transparent, there are others that be direct.

A Medical Practice Issue: Too Darn Many Decisions!

Recently an attendee at a conference answered the question about how much time do I waste with 90%! When asked if she really meant that, she said yes. There are constant interruptions throughout my day. When asked with another “why” (using the 5 why technique) it was that the staff kept asking questions. I think this is a very common trend for many administrators interruptions are impacting your productivity. Thus when we suggest implementation of Lean Principles and the use of the many tools available, the answer very often is we don’t have time.

It may be that we have not developed/trained the staff or maybe we haven’t provided the parameters within which others can and should be capable of making decisions. The staff is required to make decisions all the time. From deciding whether or not a patient who does not have their co-pay should be seen, to the patient at triage who wants to add the second child to the visit since the two kids are there, to what to do we do in a real emergency.

It would seem that if you tracked the reasons for your daily interruptions on a basic log you would begin to get patterns either by individuals, positions, or circumstances that you could begin to address. There may be immediate teachable moments.

There also may be opportunities to create guidelines for the staff to address the issues they face. Some of the guidelines will have to be addressed at the physician level and many may be addressed with common sense guidelines by you and your administrative team (assuming you have support!).

A decision involves defining the problem/issue, gathering the data, considering alternatives, choosing the best of these alternatives, and implementation. Simple straightforward model that you should use every time. The key in any of these decisions however may not be that you make them in a vacuum, instead you involve the staff on each of the steps!

The key though to long term success is follow up. The Continuous Process Improvement, CPI idea, where you re-visit the circumstances at an appointed time later, e.g., 4 weeks. You will find out whether or not the decision was appropriate and followed or if they have reverted back to their old ways. Ask the “why” set of questions to make sure that you are solving the problem that was presented.

Delegation through involvement and development will lead to better decision making but also free up more time for you to work on other issues with the constant goal of improving patient care.

Healthcare Quality Costs Too Much

In the last post, I mentioned the cost of a denial as $25 and that it is a waste time and money in your medical practice. If we really look at the idea, we should understand that to meet a healthcare quality standard, there is a cost associated.


There are four cost of quality categories to understand:

Appraisal costs: 

• These costs relate to audit and reviews of the processes in place. 
• These can be a waste, e.g., reviewing every encounter every time for every provider, even a simple 99213! Review yes, but every time NO! Identify the patterns of errors, use those as teachable moments, stop reviewing every transaction, and set up a random audit pattern later. 

Prevention costs: 

• These costs associate with training, new equipment, supplies, etc. 
• The goal here is to spend money preventing defects from occurring. These might include spell check, changing from carpet to a non-slip tile floor 

Internal failure costs: 

• These costs are what we did wrong 
• These include the demographic errors in claims submission, discussed in the prior post, wrong prescription, non-documentation of what was done 

External failure costs: 

• These costs are associated with an activity outside of the practice. 
• These might include an insurance company asking for additional information on a claim that we know is unnecessary, wrong supplies sent, back orders on supplies 

This is not to say that any of these costs are bad or good. The point is to have you recognize that there are costs associated with providing quality service to your patients.

The next time you think about cutting costs, don’t just say cut overtime, instead think about areas where there is waste, where you can re-focus the staff efforts, track where errors occur and work to fix them. If we accept the 25% of your workday is wasted premise we can find areas where costs are expended unnecessarily.

It is these costs, changing how things are done that can and will make a difference

The Medical Practice Front Desk Screwed Up Again

An insurance claim that results in non-payment due to a denial is a waste! Statistically we know that the cost of handling a denial is about $25. Costs start from input, maintenance of the account, receipt of the EOB, the RE-WORK, re-submission and the time value of money. If your practice has only 10 denials a week that’s $250 times 52 totaling $13,000. You’re not writing a check for that amount but you might as well.

The cost is in the re-work where staff can be doing something else with their time. Today’s cash flow has a greater percentage of patient payments than ever before.

The main source of denials is from demographic errors. Is that what your denial report shows? You do get and review a denial report at least weekly, right?!

Let’s assume it’s at the front desk. How about doing a Gemba and checking things out and you will find phone, patient questions, noise, copying, scanning, patient check in and check out and many other activities. Draw a process map and see what steps are there and who makes what decisions.

This simple step will create a picture, which should result in changes as to how this key area is handled. How about shifting staff from the denial management department to the front desk. You won’t need the staff in the back if the front is staffed correctly! This is an assumption and jumping to a conclusion. More importantly, it is intended to suggest that a look at your denials, making an effort to repair them by using Lean tools and determining that many activities can be changed.

Challenge one is to look at your denial report, identify the main source of denials, calculate the cost of processing them, evaluate the main source, use the time as a teachable moment, and things will improve.

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