The horse shelter at Raza's Clinic

Our friend Raza Shah, ND has a large Mennonite patient base–so large, in fact, that he actually has a place to shelter horses while patients have their appointments. So cool.

In The Practitioner’s Journey, we wrote about how my dentist used to amaze me by thanking me in person for each referral over the past year as I sat in his chair. It made me feel great, of course, and I was sooo impressed he remembered.

The truth is, he wasn’t really remembering–he or his staff simply wrote the names of people I referred in my file. As he sat with me, he could look over and say, “Thanks for referring Lisa.” A free, simple tool to get a simple, but important task done. And like good magic, even when the trick is revealed, I’m still impressed.

Raza’s like my dentist. His gift is connecting with people, and it’s important to Raza to remember the little, personal things. The problem, of course, is that you really can’t remember them–not all, anyway. To accomplish similar magic to my dentist, his office uses sticky notes in the file to remind them of the little things that are important in the lives of their patients.

“One patient had missed a previous appointment, which was very rare. When she called to reschedule, we found out she’d missed her appointment because her horse had fallen in a ditch the night before. Carol put a sticky note in the file that the horse’s name was Tony. When she came back in, I asked, ‘How’s Tony?’” – Raza Shah, ND

Needless to say, the patient was thrilled that he asked. I love this. It’s an elegant, painless and basically free way to remember important things, and communicate them between practitioners and staff.

The sticky note, though, isn’t really what this is about. The sticky note is just the manifestation of actually caring. It’s no different than putting a note in your calendar to remind you of a friend’s surgery, or your mom’s birthday. It’s just a way to make your clients feel like their lives are important. Because…they are, aren’t they? (And, no, writing it down doesn’t mean you care less, or that it’s a gimmick. The fact that you write it down at all means you care more than most.)

Your patients might not arrive by horse. But for the price of a few sticky notes, you can still perform magic of your own and show you care.

Note: I love that patients arrive by horse. Anyone else know of out-of-the ordinary practice set ups or patients? Do share…   -Dan

A friend once told me to never be held hostage to ultimatums. It’s good advice. They never lead anywhere good.

You’d be surprised, though, at how often they appear in practice.

• Your staff member says, “I need a raise, or I quit.”
• Your associate says, “I need a bigger share, or I’m leaving.”
• Your patient says, “I’m not coming in unless you stay open late.”

None of these are unreasonable things for someone to want, but when they come as ultimatums, they forgo discussion and ruin relationships. Once you give into one ultimatum, you can be sure there are others to follow.

Why We Give In To Ultimatums

One word: fear.We have a tendency to fold when presented with an ultimatum because we’re afraid of the consequences of staying strong.

• We’re afraid that we can’t live without the person making the ultimatum. I can’t pay my bills without this person’s help/rent/percentage.
• We’re afraid that we’re in the wrong. They’re probably right. I have been giving too little.
• We’re afraid we’ll be disliked. If I don’t agree, then I’m a bitch.

The truth: ultimatums hold you hostage. You might think you can’t live without someone, but the reality is that once you give in to a no-choice demand, you can’t live with them for any length of time.

Ultimatums are the grown-up version of a temper tantrum. They don’t belong in your practice.

How To Deal With Your Next Ultimatum

Does this mean that every ultimatum means you break up? Not necessarily. Often ultimatum-givers a) don’t realize quite what they’re saying; or b) don’t realize that you might actually stand up to a bully. Once they’ve been enlightened, they may change their position. Here’s how to bring the light.

1. Restate the Ultimatum in Simple Terms

Ultimatums often wear disguises. They come as veiled threats, where the subtext says, “or else” but the surface conversation is more passive.

Your first step is to drag the subtext into the light. Clarify by saying, “Just to be perfectly clear, my understanding is that you are leaving unless I do X.” Important: This is NOT a question. It’s you restating what you heard. Before they respond, you need to move to the next step.

2. State Your Position on Ultimatums

Follow that same phrase with, “If this is an ultimatum, then I accept your resignation/decision to leave/etc. If you’d like to discuss ways we can continue to work together, though, I’d be happy to do that.” Ideally, this sentence follows the previous with no break.

The goal here is simple: to clarify that an ultimatum means goodbye, plain and simple. You need to be clear that an ultimatum has no power in your relationship other than to end it.

3. Stand Firm

More often than not, the first two steps will result in some serious backpedaling on the part of the ultimatum-giver. If they don’t, then stand firm. If this really is an ultimatum, then accept their offer. Say goodbye. Thank them for the relationship to date, and move on.

Remember: The only way for the first two steps to work is if you are truly strong in your resolve to say goodbye to ultimatums. Don’t be afraid. No one is indispensable.

Ultimatums are black and white, one-sided demands that have no place in a healthy practice. Don’t be held hostage.

Contrary to popular belief, you don’t need to be booked solid to have a waiting list. It’s a tool that works wonders at any point in practice.

The challenge is that waiting lists are harder to use than they seem. Here’s how you can make one work for you and your clients with no cost and minimal effort.

The Challenge

We were doing well with our scheduling strategy, but we still had a lot of holes coming from last minute scheduling changes. We don’t double-book, over-book, charge for missed appointments or use any other fixes that I feel reduce our level of service, but we really needed to do something to get the schedule filled more effectively, while still serving clients even better.

The waiting list was the answer. We just needed to use it the right way!

The Benefits

We were already using a waiting list, but it wasn’t working the way we thought it should. This time, we fixed our process for good and noticed the following in just a few days:

• Less waiting for new and existing clients
• More client visits in fewer clinic hours
• More convenient scheduling for patients
• Better daily flow for practitioners
• Greater revenue with the same or lower costs

To make that happened required five key shifts. Not difficult ones, but each is important.

Shift 1: Work Less

In the past, we’d tend to scale up available hours as things started to get busy. Once the schedule approached the 70-80% mark, it was harder for patients to get in at certain times, so we’d add a few hours here and there. It seemed sensible – after all, if there’s not much room in the schedule, you add more, right?

Wrong. This year, we took a new approach. Faced with a busy appointment book, we actually reduced our consult hours. This was the real turning point.

Reducing available time is really a way to push the adoption of a waiting list. It forces you to find a way to truly use the time that’s available in the schedule.  Why book only 75% of 30 hours when you could book 95% of 25? The deliver similar “billable time” but the latter involves a lot less time in clinic.

The result for us? We’re seeing more patients in the new reduced schedule than we did before, and providing much better service.

Shift 2: Change the Intention

In hindsight, “waiting list” isn’t the greatest phrase. I mean, who wants to be put on a list for waiting?

In the past, we might ask someone, “Can we put you on our waiting list in case there’s a cancellation?” Many would say, “No thanks.” A waiting list wasn’t really a patient-centered offering, and people weren’t interested. And for our staff, who take our clinic values very seriously, the waiting list wasn’t much fun either. For them it felt like a frustrating exercise that was all about making the clinic more financially efficient.

The solution? We changed our waiting list to a rapid care service. I know – it sounds like fluff, but it’s not. It was a fundamental shift in the purpose of the tool. Now the staff can reassure patients who can’t get in as soon as they’d like by explaining our rapid care service that will get them in sooner. Then they delight them a day later when they say, “Guess what? We’ve got a space for you.” Patients love it. It’s helpful for the staff. The practitioners love it. And the clinic is busier than ever, with fewer wasted clinic hours.

This shift is simply about service. A waiting list that is built around the intention of, “not wasting time we could be billing for,” will never work as well as one that’s built to serve.

Shift 3: Just Start

Don’t make this a big deal.  You can start your own rapid care service with a scrap of paper taped to the front desk. That’s what we did, and it worked great. Just get started, and figure it out as you go.

And don’t wait until you’re busy. The waiting list isn’t a tool for booked-solid practitioners. It’s a way to increase the speed and convenience of services in your office for everyone from the clients to the staff to you. That means no matter where you are in your practice, day one or day one thousand, you can use this tool to make life in the office easier for everyone. Even if it’s just you and a small roster of patients, get this habit in place now.

One of our early problems was making this bigger than it needed to be – that kind of thinking puts up too many roadblocks and “buts.” Just get started.

Shift 4: Get Involved

A real turning point was when I manned the front desk for a few days over the school break when we had some staff shortages because of vacation. It’s a job I used to do more in the clinic’s early days, but haven’t done much recently. It’s a great way to appreciate a) the challenges of filling a book effectively, and b)just how often a waiting list can be put to work.

You may be doing your own scheduling, and know exactly what those challenges are, but if you haven’t done the job in a while, it’s worth making a few hours to live in your staff’s shoes by answering the phone and booking appointments.

If you’re not doing your own booking, you’ll still need to be on top of gaps in the schedule. Make a point of checking the schedule regularly through the day. Help your team think of ways to fill any holes. “What about Mrs. So-and-So? She could come in.” Getting your waiting list to work is about changing habits, and that’s going to require you to be leading the charge.

Shift 5: Collect Better Information

To make this work, you’ll likely need to start learning more about your patients than you currently do – or you’ll at least have to start writing it down somewhere. Focus on these three areas:

• Best contact: To make your system work, you need more than just a way to get in touch with people. You need the fastest and most certain way to reach them. If you have a sudden opening in the schedule, you won’t be able to fill it quickly if you’re calling someone at home, but they’re at work for the next six hours. That means you need to know the best way to reach them now. Is it their cell phone? Email? Text? Work number?

• Patient preference: You waiting list needs to have some details – like what service patients are waiting for, and their preferences for times and days

• Patient flexibility: You’d be surprised how many clients have flexibility in their lives. The trick is to know who those people are. They’re the ones that are going to be a) great candidates for your waiting list, or b) the people whose appointment you can shift to accommodate someone else on the list who’s less flexible, and waiting for a specific time slot.

How you collect that info is up to you. Whoever does your bookings will develop a good sense of patient flexibility and preferences, but only if they ask in the first place. You need to be asking patients this information during the booking process. If you can’t reach flexible people in the fastest way possible, your list is going stumble before it gets out of the gate.

Small Effort, Big Benefits

Once you get this in place, you’ll find the benefits tend to spread into the schedule. When you have a great intention, and you can reach flexible clients easily, it become easy to shift the schedule to make it more efficient even when there aren’t people waiting. That frees up more blocks of scheduled time that help you get people in right away without ever having to be on the rapid care list at all.

Don’t be scared to work less to make this work. Test-drive it for a couple of weeks – you’ll be surprised not only at how efficient you can be, but how well your clients will respond.

We’ve in the middle of a long recruiting process to fill out the rest of our clinic team. We’ve hired a few faces over the years, and right now I feel like we have our best staff ever, with one position remaining.

There is no more important thing than having the right people. I’ve watched the transition of a single person on or off the roster make a difference of tens of thousands of dollars in a very short time, not to mention the impact on morale and joy in the office. It’s phenomenal. Here are a few tips we’ve learned along the way.

Find The Right Candidates

You’ll be most successful when you’ve got lots of options. Attract good quality applicants to choose from using these tips:

• Don’t Advertise… Seriously – forget about the classifieds ads and the internet listings. First of all, it’s time consuming to sort through the resumes, and second, it’s hard to read people from a sheet of paper. You’re just as likely to toss a winner in the shredder and interview five bad fits as you are to identify a great candidate.

• …Unless you Have To. The exception to this is when you’re recruiting for a position that needs some legitimate certification. If you need an ND, DC or an LAc, for example, you may have to advertise to find licensed candidates? Front desk? Nope.

• Network Instead… The best jobs are found through networking, and so are the best candidates. Not all, but on average, the best are. Spread the word through your friends, family, colleagues and patients. CAM offices are great places to work – you’ll get response if you get the word out.

• …Or Headhunt. There’s a great chance your ideal candidate already has a job – go find them. If you have a great experience with someone in another business, why can’t they work for you? The job you have to offer might change someone’s life – don’t be afraid to offer it to someone already working.

Choose the Right One

Once you’ve got a pool of applicants, it’s time to find your winner. Here are a few rules of thumb:

• First impressions matter. Reception/front line jobs tend to involve short bursts of surface interaction. A moment here, a smile there. A quick swipe of a credit card and a brief chat. A voice on the phone. Make sure you get a good first impression, and be wary if you don’t.

• Trust Your Gut. Your intuition is your best friend at hiring time, particularly when it comes to negative vibes. If something doesn’t feel right, it probably isn’t.

• Hire for Personality First. This is health care, not widget-making – great people skills are critical for almost all positions. You can teach most hard skills, but a great way with people is almost impossible to learn.

• Test-Drive Before You Hire. This is a great strategy, and has saved our butts more than once. You simply can’t trust an interview entirely. If you’ve narrowed your choices down, then bring them in for a half or full day and see how they do. Pay them for their time for the day – it’s worth the investment.

• Aim to Be Amazed. Don’t settle for someone you know isn’t right. Set your sights high. If it’s an emergency, then hire someone on a clearly defined temporary basis while you look for your dream person. They really are out there.
• Consult your Team… If you’ve got other staff, get them involved. A bad fit will cost you. Let the other people in the clinic help out.
• …and Your Patients. Remember that test-drive? Make sure you get some patient feedback. You might even consider asking some wise patients to drop by that day, or participate in the interview process.

It’s easy to second guess yourself in this process, so make sure you have help. And take your time – finding the right person makes all the difference.

We’ve discussed scheduling problems in the past, pointing you to a few resources here and there, but we’ve never really provided a comprehensive approach for those scheduled appointments that go off the rails due to patients canceling, rescheduling, or simply not showing up at all.

Here are the exact strategies we’ve put in place over the last few years. If you’ve got something that works in your practice, leave a comment and share it with us.

Make Reminder Calls
We all forget things, and appointments (particularly those with a long lead time) are among the easiest things to lose track of. Appointment cards are helpful, but in the end, a phone call is your best bet. Email, text message and other automated solutions are starting to make some headway, but a good old-fashioned telephone call is still the most effective tool to combat schedule disintegration.

• Provide some lead time. Don’t make your calls the night before. Give patients at least 2-3 days notice.
• Don’t leave wiggle room. Saying, “Call us if you can’t make it,” is an invitation for people to reschedule.

I don’t think we started making these calls as early as we should have. When you’re not busy, it can feel like it doesn’t matter as much, but the truth is that it does matter. In fact, you could argue that it matters more – those cancellations are pretty painful in the early days.

Some practitioners argue that reminder calls encourage people to reschedule. I don’t buy it. Better to know, and take steps to deal with it, then have a sudden hole in your day.

Stay on Time
If you want patients to respect your time, then you need to start that process by respecting theirs. Make sure you stay on time. Don’t reschedule patients. Keep regular office hours.

Yes, emergencies crop up, but your clients will accept that if you explain it to them, apologize, and don’t let it happen regularly.

Book Tightly
What we’re really after here is teaching your patients to value their appointment. A large part of that is demonstrating that you’re busy and run a tight ship. Many practitioners tend to spread patients out over the course of a day, but for us the looser the schedule gets, the more reschedules we seem to encounter – patients figure they can get an appointment on just about any day, so what’s the big deal? It is a big deal, and it starts with effective scheduling.

Don’t Overbook
However, if you’re tempted to treat your appointment book like a discount charter flight and book it 120% full, you’re going to have problems. Overbooking to deal with last-minute scheduling changes is like treating symptoms instead of causes – it’s not getting to the root of the problem. In fact, just like running late, it’s probably creating more of them.

Book Acute Care Visits ASAP
Acute care visits are fertile ground for scheduling glitches. When patients call with an acute care issue, it’s because they want to be seen now. If you can’t see them soon, recognize the fact that they might get better or find someone else in the meantime. That increases the likelihood of a no-show or cancellation.

Follow the 1-2 Month Rule
When a patient wants to reschedule or cancel, remind them that they may not be able to get another visit for 1-2 months. Patients often reschedule simply for convenience, and this technique can often resurrect the appointment. You can read more on this approach here.

Deal With Repeat Offenders
You may discover that a large proportion of your problem appointments are with the same small group of patients.

We do have a no-show fee, but we use it with discretion. And while we don’t often charge people for missed appointments – unless they have some hard cost like custom formulated IV treatments – we do try to educate these people over time by explaining that someone else could have used their time slot.

Failing that, we follow a three-strike rule. After they bail a third time, we usually don’t hurry to call them back. If they call, we try to fit them in that day, or tell them to call back again another day when we might be able to provide same-day service.

Track Your Results
Although you may have a general sense of how well your appointment book holds together over the course of a month, nothing beats having some hard data. The easiest way is simply to have your staff track the numbers. This also lets you identify patterns that might crop up based on the time of day, week or year.

If your software doesn’t do this for you, it’s still easy to implement using pen and paper. Head to CalendarsThatWork.com, and print a lined version of their monthly calendar. Use the first line for reschedules, the second for cancellations (with no reschedule) and the third line for no-shows. Have your staff just put a tick on the appropriate line each time, then add them up at the end of the week/month. You can even enter your email address, and the site will send you the same calendar just before the start of each month.

Everyone has a role to play in keeping the schedule healthy -you, your staff, and your patients – and much of this is about teaching everyone involved about the value of a scheduled appointment. Consider yourself the Dean of the School of Appointment Value, and train your students accordingly.

We’ve noticed some dramatic improvements over time using these strategies – if you’ve got any other tips, we’d love to hear them!

Reader W., a naturopath, is facing a staff ultimatum: “I need a raise or I quit.”

What’s the best thing to do?

a) Give In
b) Do nothing/ Call the Bluff
c) Negotiate
d) Accept The Resignation

This situation is more common than you think. Keep an eye out for it in your practice, as it often comes in more polite form – something like, “I can’t seem to make ends meet with my current paycheck. I’m so sorry, but I’m going to have to leave unless I get X.”

Here’s your answer: any time a staff member uses “quitting” as leverage to attain something, the only viable option is to accept the resignation.

No matter how polite, this is a form of bullying on the part of the staff member. They may truly need the cash, and they may not be playing hardball consciously, but the long-term impact on your practice will still be negative. Here’s why:

They’ll Do it Again
Once they see that the tactic works, your staff will use it again for something else in the future. It’s simply the way our brains are wired – positive reinforcement is a powerful tool.

They’ve Already Decided They’re Willing to Leave
In most cases, the person has already accepted the idea of leaving. Even more likely, they’re probably looking for another job right now. They’ve got one foot out the door.

They’re Likely Uninspired at Work
If they really loved their job, they’d find another way to ask for a raise, one that doesn’t come packaged with the or else clause. This is why ignoring the situation or calling the bluff may not work – the original ultimatum is an indicator of a larger problem. As soon as they play the “I’ll quit” card, they’ve shown their hand – if they haven’t got one foot out the door looking for more work, they’ve certainly got half their mind somewhere else.

They’re Setting an Example
If you’ve got a staff of more than one, giving in to this type of negotiation tactic sets a precedent in your practice that may lead to more difficulties down the road.

Although letting someone go is possibly the hardest part of being an employer, it’s also one of the highest impact decisions you can make in your practice. It may seem rash to simply accept their resignation, but in the long run, you’re always better off with the right person in the job. It may help to think of it as helping the other person find what they really need – giving in and keeping them on staff isn’t likely to make them happy.

Or else scenarios are harbingers of future problems with staff. The double gift of the ultimatum is that it let’s you know things aren’t going to work out, and it offers you the easy way to let the person go: they’ve offered the resignation; you just have to accept it.

We did a little experiment a while back that I thought was worth sharing.

In the early days of practice, many CAM docs struggle with whether or not to hire someone to answer the phone and take care of other admin tasks. After all, it may not even be ringing, right? Who wants to pile a receptionist salary on top of all that business and education debt?

The truth is, in the very beginning, it’s not a big deal for a lot of practitioners. The problem arises when you start to grow and can’t answer those calls yourself. At this point, many practitioners use the fallback solution of voice mail to save on staffing costs.

I was always suspicious, though, about how many people actually left a message when they couldn’t get a human on the phone. After all – I hang up a lot when I can’t get someone in person, why wouldn’t patients?

Enter the experiment. While we were on holidays, the receptionist took some vacation too, with the exception of one task: checking phone messages. Rather than just phone in to retrieve them, however, we asked her to come into the office and use the call display information to track how many people had called, versus how many actually left messages.

The results were insightful: only a third of callers left a message.

With a full-time receptionist in the office, every one of those calls would have been answered, and many converted into appointments. Moreover, those appointments would have filled a few holes in the schedule immediately after our holidays – time that can never be “gotten back” from a billing perspective.

The point here is not just to convince you to hire staff, but also to make sure that have staff that view incoming calls as a priority. Each call is a potential opportunity to fill an opening in the book, or gain a new client. And as we’ve discovered, you can’t rely on voice mail to do the job. It’s just not the same.

Physicians Practice has an article on the importance of the front desk / receptionist position in medical offices, and some tips on how to attract them and keep them.

Almost everything in the article applies just as well to CAM and holistic practitioners – it’s worth a read.

The summary: screen them well, pay them well, train them well. Which is another way of saying “take the time to invest in your front lines”, a mantra you’ll frequently hear around here.

Link

Note: You’ll have to answer a couple of anonymous zip-code/occupation questions to read the whole article.

SoundPractice.Net has a free podcast on finding the right office staff. It caters to the MD crowd, but there are few interesting points in the 20-odd minutes.

Perhaps even better, there are over 100 free podcasts on the same site…

SoundPractice.Net – Podcasts for Medical Practice Management and Health Care Administration

(For a full list of all the podcasts, check out: http://www.mpmnetwork.com/page.cfm?name=featured_content )