Three games to drive your business.

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The team won’t play at their best unless they are emotionally engaged – and that happens when they can tell if they are winning or losing. – Chris McChesney

People work harder when they are keeping score. If you don’t believe this, just hold a competition around anything… fundraising, customer service survey results, even completion of compliance items. Games are a great way to engage your team, often with surprisingly effective results.

Here are three games you can play to meet common challenges in physical therapy private practice.

1) Ever find it hard to motivate your team to consistently perform marketing activities?

The featured image this week is an amazing scoreboard created by one of our teams to track a contest they held over the course of 3 months. All of the staff (including front desk personnel, therapists and aides) formed teams that competed to earn points. Each time a potential referral source was contacted in person (5 points), via phone (2 points), handwritten note (1 point), etc. the team advanced along the racetrack. The goal was for every team to complete the race to earn a clinic celebration. This not only became a team building exercise but this group generated more than 400 referral source contacts in a single quarter. All those contacts paid off; the following quarter they broke the clinic record for the number of new patients referred.Kiss halloween

2) Ever felt like your social media efforts are stale and require too much effort?

Have a team halloween costume contest! Texas Physical Therapy Specialists’ annual halloween contest has a $300 first prize. Each team chooses a theme and creates a video that is uploaded to youtube and linked to on Facebook. Patients are encouraged to visit the Facebook age and vote for their favorites. This single event drives more traffic than any other during the year and engages the entire company in a fun, team building activity. The prize goes to a team celebration which creates even more camaraderie and social media content.  Check out the 2013 winners!

yelp-5-star3) Want to fill Yelp! and Google Plus with positive reviews?

Place a laptop ready to go and have a staff member help patients leave reviews as they graduate. As a thank-you for participating patients choose a prize – a branded t-shirt, tumbler or coffee mug or enter them into a raffle for a larger prize. Create a scoreboard that tracks how many 5-star reviews your team has received with a celebration once the goal is achieved.

Set a goal, design a game and build a scoreboard. Friendly competition can be a great way to mobilize your team. I would love to hear about games you have played to drive your business forward – what is working for you?

What is Quality in Physical Therapy?

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I have had some interesting interactions in social media over the past few weeks that have had me thinking about the definition of quality in physical therapy. Therapists are paid for our time and the procedures we perform. Because of this (or at least I blame this system) we tend to define quality around ‘actions taken’ and method of work. For example:

  • Quality providers are able to manipulate an acute low back
  • Quality providers avoid modalities
  • Quality providers provide good home exercise programs
  • Quality providers set and track goals
  • Quality providers use evidence based interventions
  • Quality providers spend (however long) with each patient
  • Quality providers do not use PT Assistants or Aides
  • Quality providers have this or that certification
  • Quality providers have/avoid the latest gadgets
  • Quality providers use/have/do whatever is important to you…

We do this in large part because these are the most visible parts of a practice we might judge it by. However, I would argue that while there are a host of factors that the best practices have in common, quality is not defined by actions or our broken reimbursement system. Quality is defined by patient outcome and by patient experience. In this post, I’d like to provide a window into how we measure quality at Texas Physical Therapy Specialists.

In our practice, we measure outcome using a national database called Focus on Therapeutic Outcomes (FOTO). This system uses adaptive surveys to determine a risk adjusted baseline when a patient starts physical therapy, and then tracks their progress. The results can then be used to provide feedback to individual therapists (i.e.”Dr.____, your outcomes with ankle patients aren’t as good as Dr.___’s, lets see what they are doing that you are not) and more importantly can be used to compare outcomes with other participating practices across the nation.

The other component of quality in physical therapy practice is patient experience. We break this into two components: customer service (all staff interactions) and providing quality connection between the therapist and the patient.

We measure customer service with a survey that has multiple components but centers around the ‘net promoter score‘. Often called ‘the most important question in business’ it is simple and captures the desired customer service outcome for most practices.11268773_m

“How likely is it that you would recommend us to a friend or colleague?”

Much harder to measure but equally important to patient experience is the quality of connection between patient and therapist. This is how well a therapist listens and how much empathy they show. These things have a powerful impact on clinical outcome so we measure them separately using a survey specifically for these items (Consultation and Relational Empathy instrument or CARE) at the completion of the first visit. Interestingly, our therapists scored significantly better in this area after receiving training specific to compassion and empathy.

The confluence of these three things is the product our practice produces.

The amount we charge a cash-paying patient, the contract we sign with an insurer or the assignment we accept from the federal government is simply how we receive payment for that product.  Our current payment system bases this on time spent and a host of other items that have no direct relationship to quality.  Paying for time without accounting for outcome is like paying a mechanic for the time spent on your car without accounting for whether the problem is solved.  Regulating work methods is like mandating that a mechanic can’t use helpers and again not accounting for whether the problem is solved.  We have to comply with these external definitions (which vary wildly by state and payer) but we do not have to let them define what Quality is.  In my opinion, quality in physical therapy is a simple equation:

Quality = Outcome + Patient Experience.

There are many ways to get there, and undoubtedly some are better than others.  Having the ability to measure quality gives us the opportunity to find bright spots and emulate best practices.  How do you measure the quality of your service?

…and fire quickly.

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I have never met a leader or a practice owner that regretted firing somebody that was a poor fit for their team. While I have not had to let many of my teammates ‘find other, more suitable employment’ one example comes to mind.

DOFIStacy (not her real name) was a pretty good DOFI. DOFI stands for ‘Director of First Impressions’, a title shared by all of our front desk personnel. All the patients loved her and she took care of the data entry and scheduling portion of her job well enough. The downside was that she was often late and her ‘sick days’ tended to fall on the Friday before a 3-day weekend. I must have put up with a half-dozen ‘throat hurting’ and family emergencies (I think her grandmother died twice) and way too much aggravation before she finally pushed me over the edge. After a very dramatic sick call, she posted some great pics from the lake on Facebook! We let her go the next day, only to find out that she had been stealing co-pays from patients for on and off for over a year.

Lesson learned! I should have let her go as soon as I figured out that she had an integrity problem. Here are a couple of relevant quotes to help us remember to make the decision to remove people from our team more quickly.  I find that it helps to think of ‘firing’ as rectifying my own mistake in hiring the wrong person.

“The moment you feel the need to tightly manage someone, you’ve made a hiring mistake” (Jim Collins)

“Don’t beat yourself up if you get hiring wrong some of the time. Just remember, the mistake is yours to fix.” (Jack Welch)

So if you find yourself tightly managing someone or smelling a culture mismatch, move into addressing the problem without delaying to see if it will rectify itself. If its a problem with competence, you should be able to address it and see improvement. Chris McChesney of Franklin Covey said it best:

“If they can’t do it, they are in the wrong seat. If they won’t do it, they are in the wrong organization”.

Hire slowly…

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One of the most important decisions in building a great practice comes whenever we are hiring people. Likewise, one of the surest ways to destroy a great culture and derail growth is to pick the wrong people for your team.

“The old adage people are your most important asset turns out to be wrong. People are NOT your most important asset. The right people are.” – Jim Collins, Good to Great.

This principle from ‘Good to Great’ has been useful lately as we go through a round of hires at Texas Physical Therapy Specialists. Whenever we find ourselves in a position of needing to hire, inevitably the growth or circumstances that necessitates the hire pushes on us to accomplish it quickly to remove the pressure. The challenge is that this is the best time to slow down and be disciplined and rigorous.  Its painful (just ask my directors waiting for help!) but it pays to put in the energy up front and hire the right person.26325920_s

Here are 4 of my favorite rules to help us make this important decision:

  1. Cast a broad net. You want to make sure that you capture a large pool of applicants, rather than a sample of convenience. Sometimes a ‘good’ applicant appears fortuitously – making the path of least resistance a quick hire without much need for rigor. What if the 5th or 10th applicant would have been somebody great?
  2. Don’t compromise. The surest way to build a mediocre team is to hire mediocre people. Deal with the short term pain of the search and hire the very best you can find. The long term pain of a mediocre hire is worth avoiding.
  3. Hire for attitude, over aptitude. Unfortunately, we don’t always have the luxury of waiting for that perfect candidate to come along or we have to choose between two great people. When we do have to choose, we should give attitude and fit within our culture greater weight than competence and skill set.
  4. Do more than an old school interview. There are alot of tools out there to help you dig into who a person is. Consider using tools like the Omnia profile, Emotional IQ, Strengthsfinder or the VIA character strengths profile to give you a window into your candidate. Using this type of tool (don’t try to use them all) will make you slow down and think deeply about who you are hiring and their fit within your team.

party-busPackard’s Law captures why getting the right people on the bus is so important:

“No company can grow revenues consistently faster than its ability to get enough of the right people to implement that growth and still become a great company”. – Jim Collins, How the Mighty Fall.

Take the time to hire slowly…. and the second half of that adage is … fire quickly. We’ll talk about kicking people off the bus next time.

What does the Hedgehog say?

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One of the most elegant and useful concepts from Jim Collins’ Good to Great study is the Hedgehog Concept.

The Fox knows many things, but the hedgehog knows one big thing – Archilochus

In his famous essay “The Hedgehog and the Fox“, Isaiah Berlin divides people into two groups: foxes that see the world in all its complexity and pursue many ends at the same time vs. hedgehogs that condense concepts and reduce challenges into simpler ideas.  The parable would have the crafty fox attack the hedgehog with a variety of clever strategies, to be repeatedly beaten by the hedgehog’s simple, but powerful strategy – roll into a ball so the pointy parts are facing out.   While the fox is crafty and nimble, the hedgehog is focused, determined and stays the course.

The companies that went from good to great discovered and then had the discipline to stay within a foundational hedgehog concept that kept them from being distracted from their core business.  In contrast, the comparison companies that never made the leap to greatness often lost focus and took opportunities that were outside of their strengths.

A hedgehog concept is found at the intersection of three dimensions:

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  • What you can be the best in the world at.
  • What drives your economic engine.
  • What you are deeply passionate about.

The good to great companies (compared to comparison companies) were disciplined enough to understand and stick to their Hedgehog concept despite the temptation to chase after increased profits or ‘once in a lifetime opportunities’.

In the medical field we see some great examples of finding and sticking to a hedgehog concept.  One local example is a practice called Sullivan Physical Therapy.  This practice has a niche – women’s health – that they are great at.  Another is Balance 360 that focuses on balance and vestibular disorders.  In these cases, these practices don’t try to be all things to all people – they have a concept that they can be the best at, that drives their economic engine and that they are passionate about.

I don’t think that the hedgehog concept applies only to practice niches, though.  At Texas Physical Therapy Specialists, we can be the best in the world at developing clinical specialists and team leaders.  This is where our passion lies and the team it produces drives our economic engine.  By understanding and sticking to our hedgehog concept, we have the potential to be the best in the world.  We have to have the discipline to avoid ‘once in a lifetime opportunities’ that don’t fit within our concept and we have to have the discipline to stay the course when it seems like jumping to a different strategy might be more effective.

What’s yours?

Jobs Applied: Know Both the Big Picture and The Details

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Steve Jobs had a penchant for dreaming big.  His far-reaching vision brought personal computers into the home, revolutionized the music industry and contributed to the advent of today’s world of cloud computing.  Yet at the same time, he also kept his hands in the nitty-gritty details of the products Apple was producing.  He set not only the destination of Apple, but he paid attention to every turn along the way.  This ability to ‘zoom out’ to the big picture and ‘zoom in’ to focus on details is part of what made him so effective.

Small business owners, particularly in service industries like physical therapy, are often pulled in a thousand directions.  We have to make decisions on a grand scale – ‘Do I buy this building?’, ‘How big do I want to grow?’, ‘should I participate in this ACO?’.  However, we also have an overwhelming flood of details to oversee.  ‘who has the best price on theraband?’, do I have time to put another patient in my 2:30 slot?, ‘should I give my technician a $.25 raise?’.

“Details matter, it’s worth waiting to get it right.” – Steve Jobs

Focusing in on just the big picture can create problems.  In today’s challenging payment environment, the margin is often found in our management of expense details and avoiding unnecessary costs.  It takes almost $1.25 of revenue growth to equal $1.00 of cost savings.  This means that controlling costs is often an underutilized mechanism for improving performance.  The success of our teams often also happens due to paying attention to details.  Getting the right people on the bus and making sure that we only tolerate A players has everything to do with careful selection of every member of our team.14866993_m

However, focusing only on the details stifles innovation.  Strategic thinking, big picture goal setting and innovation are necessary ingredients for a vibrant culture and practice growth.  We have to have a vision and a strategic plan for reaching that vision.  As Vince Lombardi said “hope is not a strategy.”  As leaders in healthcare, we have to be part of the nationwide conversation going on right now.  We need to be involved in coming up with the ideas that guide our changing healthcare system, and we will need to be ready to adapt to the new reality that is coming.

“I want to put a ding in the Universe” – Steve Jobs

To grow and to be successful we have to know both the big picture and the details.  

This Jobs Applied lesson reminds me of one of my favorite principles from Jim Collins.  My next #Browdering series will apply this principle and several others from ‘Good to Great’, ‘Great by Choice’ and ‘How the Mighty Fall’ to our world of physical therapy management and leadership.  I hope you will join me next week as we discuss ‘The Stockdale Paradox’.

Jobs Applied: Engage Face to Face

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“There’s a temptation in our networked age to think that ideas can be developed by e-mail… that’s crazy. Creativity comes from spontaneous meetings, from random discussions.” – Steve Jobs

While he valued face to face engagements and meetings, Jobs had nothing but disdain for the typical corporate ‘death by powerpoint’ session. What he looked for was live engagement and problem solving.

The hectic pace of physical therapy, with what sometimes seems like every moment taken by scheduled patient care makes it difficult to create time for face to face engagement. While we occasionally make time for clinical education activities like journal clubs, it is easy to replace face to face engagement for leadership activities with phone or email communication.

Creating regular face to face engagement is difficult in organizations like our private practice, with 17 facilities spread across a few hundred miles. In even larger companies with hundreds of facilities, face to face engagement between executives and local team leaders is even more rare.  My short stint working with US Physical Therapy (we were temporarily partners after an acquisition) showed me the reality of this.  The executive I reported to had about 260 direct reports.  We met face to face perhaps twice each year.

Face to face engagement… which we affectionately term 121s (one to ones) between a leader and those they lead is a key leadership task. In my opinion it is a key component of the cadence of accountability we should try to maintain with our teams. One of the most difficult but most rewarding activities we have undertaken as our practice has grown has been to maintain a regular regimen of contacts between our leaders and those they lead. Here is an example cadence that has worked well for me:

  1. Weekly – small group, very focused video teleconference focused on activities being completed to meet our most important goals.  We do 3 of them to allow small groups so they take no more than 20′.
  2. Monthly – face to face 121s between leaders and those they lead.
  3. Quarterly – Summits with key leaders meeting to share results, insights and progress toward meeting goals.
  4. Annually – Strategic planning with a small, focused group and then subsequent meetings to share aspirations and strategies with the entire team.

I believe that your average ‘meeting’ is a great way to avoid working. That said, focused face to face engagement and communication between leaders and those they lead is essential to building a great team.

Jobs Applied: Tolerate Only ‘A’ Players

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Steve Jobs, despite all of his redeeming features, was famously ‘impatient, petulant and tough with the people around him”. He also delivered results, while maintaining a loyal cadre of high achievers that stayed with him much longer than was typical of the computer industry at the time.

“CEOs who study Jobs and decide to emulate his toughness without understanding his ability to generate loyalty make a dangerous mistake”. – Walter Isaacson

Jobs believed that part of his job was to unfailingly deliver the brutal truth, rather than sugar coat failures. His belief was that many organizations employ managers who are so polite and forgiving as to become ineffective, allowing mediocre employees to feel comfortable and thus encouraging them to stay.

Jack Welch, famed CEO of GE had a similar style and philosophy when it came to an intolerance for mediocrity. Indeed, Jim Collins, in ‘Good to Great‘ found that one of the key features of great companies is that they were good at ‘getting the right people on the bus’. Along with that inevitably comes the need to get the wrong people off of the bus. GE famously utilized a performance feedback system that systematically ensured that the bottom 10% of employees were terminated or rehabilitated… slowly raising the bar for all employees.

Leaders and managers in physical therapy practices attempt to hire the strongest clinicians, with an attitude that lends itself great customer service and teamwork. This gets more difficult in tight job markets or when timing limits our choices. The adage of ‘hire slow, fire fast‘ is often harder to do than we like, and it goes without saying that the best time to ensure we have the right people on the bus is during the hiring process. We occasionally hire someone that isn’t a good fit (a C or D player). These are difficult enough to deal with.   Even harder than the obviously insufficient are those that are ‘OK’, the B players.26325920_s

By tolerating ‘B players’ we prevent the opportunity for an A player to join our team. True – we can develop B players into A players… but when you determine that they are a B player with no potential, they can set the bar for everyone around them. A team member’s status as a A or B or C doesn’t have to be defined only by phenomenal clinical skills, or amazing personality or steadfast work ethic… although it could mean any or all of those things. We should employ good clinicians with great empathy and a strong work ethic. We should employ great clinicians with good customer service skills and great ability to teach others. We should employ resilient, gritty grinders that never complain and make sure that the work gets done. But we should never tolerate mediocre clinicians with an OK attitude that give us no reason to complain.

How we deal with professionals that ‘meet standards’ or are ‘good enough’ determines whether our practice is doomed to mediocrity or if it has the capacity to be great. Tolerate only A players.

Jobs Applied: Push for Perfection

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Steve Jobs was a famous perfectionist – often delaying the release of a product until a minor issue could be reworked, or even totally scrapping and reworking a design that didn’t feel right. A famous example is the design of the Apple retail stores. He famously delayed the initial openings several months to reorganize the layouts around activities instead of product categories.

Successful physical therapy practices are constantly working to improve the patient’s outcomes and overall experience. In order to provide consistent services efficiently, countless processes have to be accomplished behind the scenes. We should always be looking for places to improve – striving for perfection in the areas that are most important to our customers.  However, we can’t be perfect at everything – down that path lies a lack of focus and likely mediocrity at everything. How do we decide where we should focus?

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In Nov 2013, Larry Benz and I presented the results of a conjoint analysis of ‘what patients really want’ to well over 500 passionate attendees of the Private Practice Section annual conference. This was a University performed, privately funded study that surveyed almost 500 patients, from 3 companies with 31 outpatient facilities.

This is was patients told us they value the most in their physical therapy experience:

  1. The therapist is very knowledgeable.
  2. The instructions from the therapist were very clear.
  3. Appointments are on time, with a minimum wait time to see a therapist.
  4. All the staff is very friendly.
  5. A doctor recommended this clinic.

These are the things that we should strive continually to improve upon, even at the cost of not improving in other areas.  Focusing on these areas with the laser-like focus and dedication that Steve Jobs exemplifies will allow us to push for perfection in the most important areas for our practice.