THE HRD CHALLENGE FOR 21ST CENTURY GP: Manpower Management in Medical Practice
Ashok V Khanvte
Family Physician, Lower Parel, Mumbai.
When we qualify as doctors, little do we realize that in managing our medical practice we will have to fulfill the role of a practice manager as well. Indeed the Family Physician has to fulfill this role without any formal training. This paper is aimed at getting my fellow Family Physicians better equipped in the Art of managing their manpower.. indeed a challenging task for the family Physician of the Y2 Kalyug. This will prove beneficial to us in better management of our patients by improving the quality of service a leap in the direction of our long cherished and Challenging goal of Total Quality Management in Family Practice.
Let me begin by asking you friends
Who amongst us would like to have a professionally satisfying and financially rewarding medical practice managed by a team of efficient, enthusiastic and committed staff and achieved by improving the employee productivity and morale?
I am sure I would get an instant affirmative reply to this question from everyone.
Management is the production of desired results by optimum utilization of the resources available in an organization
It is a well established fact that the resources at our disposal are (1) Money, (2) Materials, (3) Machinery, (4) Methodology and (5) Manpower. With regards to Medical Practice the above factors could broadly be explained as follows.
1. Money = i.e. the starting and running capital.
2. Materials = Tablets, Mixtures, Dressing materials, visit bag etc.
3. Machinery = Glucometer, X-Ray machine, ECG Machine, Computers etc.
4. Methodology = Dispensing/Consulting practice; Total Quality Management; Diagnostic General Practice; Vaccination Centre etc.
5. Manpower = GP, Practice manager, Receptionist, Assistant Doctor, Compounder, Laboratory technician, Data entry operator, house keeper etc.
From the above definition we can see that ultimately it is the MANPOWER that is going to utilize the other four resources. Without the manpower the other four resources would remain unutilized. Thus Management in essence is Management of the Manpower or MAN-MANAGEMENT. Hence we shall concentrate on our subject "Manpower management to get the most out of our medical practice". Peter Drucker a leading management thinker says - "Real management is the management of the people. People are the key to success. And managing people effectively is the factor that separates the haves from the have-nots in the field of management".
The success of every organized activity be it a business, clinic or a hospital depends upon the total attitudinal skill of its leaders. Hence a manager has to be a LEADER and apart from Managerial skills, he must have sharpened Leadership skill - which is attitudinal.
Who is the Manager? When we qualify as doc tors, little do we realize that in managing our practice we will have to fulfill the roles of a practice manager, CEO, Director HR, Chief Financial Controller, MD Advertising and Marketing and Director of Research and Development. Indeed the GP has to fulfill all these roles without any training and at the cost of time that could be better utilized in sharpening his professional skills. Hence I am strongly in favor of professional managers coming to the aid of medical professionals, especially with the advent of group practices! Thus when I use the term Manager it would mean the Doctor acting as a manager or the practice manager as the case may be.
The styles of General practice vary so amazingly vis a vis records, appointments, clinic/visit practice, Dispensing/consulting practice, specialized services, number of staff employed, timings etc that it becomes impossible to formulate a universal solution applicable to all the practitioners. Keeping the above mentioned limitations in mind, I have attempted to broadly divide the practice into Simple GP and Diversified General Practice.
Simple General Practice comprising of
3) Practice Manager cum Receptionist and
Diversified General Practice comprising
2) Assistant doctor,
3) Practice Manager,
4) Laboratory Technician,
5) Receptionist cum Typist,
6) Data Entry Operator,
7) X-Ray Technician,
8) Compounder and
Management of Manpower in Simple General Practice : Usually these are the practices where the GP sees anywhere from 50 to 200 patients in a day. I have a friend who claims that on an average day he sees one patient every 3 minutes. Because of the sheer magnitude of the workload on GP’s shoulders and having once been one such practitioner I know there is no time for even thinking about staff management or any such cultural change.
As a result the management yardsticks that I am outlining are for the family Physician who wants to receive the new millennium head on, not afraid to embrace the challenges of change, willing to supplement and complement the traditional visit bag with the black bag (laptop) and Stanley Davidson’s Medicine book with Peter Drucker’s book on management.
Over the coming years, the practice scenario is going to change so drastically that unless we ride the tidal wave of change, brought about by the Insurance companies entering the health scenario, we will be swept under this very wave. It is high time we gear up for this challenge by providing wider range of services under one roof, for the benefit of our patients. This is where we will need the art of manpower management.
Management of Manpower in Diversified General Practice
I don’t mean to undermine the efforts and the role played by my colleagues having a mass practice base. In spite of the sheer magnitude of their work, I am sure they will find many practical points in this presentation, which they could apply to their practices.
Having been trained in manpower management and advanced leadership, I have found that the following Twelve Golden Principles (management tools) could be compiled together as a guide to any GP aspiring to manage his staff more efficiently.
I call them the Twelve Apostles of the Practice Manager’s Gospel
1) Staff selection (Appointments), 2) Salaries, 3) Planning, 4) Organizing and Delegating, 5) Co-operation, 6) Accountability (performance appraisals), 7) Supervision, 8) Training, 9) Motivation, 10) Teamwork, 11) Human Relations and 12) Communication.
Staff Selection : (A) According to our set up we should decide upon the exact number of our staff requirements, demarcate the position and responsibilities of the staff we need. We must be clear about the salary range we can offer and the timings. (B) Advertise in an English paper with wide readership stating clearly the position vacant, timings, sex (male/female) preference and qualifications desired. (C) We must select a person who has scope to grow in the appointed position. If he stagnates in his job then we are doing disservice to ourselves as well as to the job aspirant. This is why I have always found it beneficial to take freshers for any job position since they are enthusiastic and can be molded as per our requirements.
Staff Salaries : Before selecting the staff we have to decide on the salary we are prepared to pay the selected applicant. We must always ask the applicant to specify the expected salary. We must offer the salary keeping in mind the experience, expertise and the qualifications of the staff. One must always be open minded about the increments and perks due to the staff members. These should be linked to their performance, behaviour, compatibility with other staff members, attitude towards patients and willingness to shoulder new responsibilities.
Planning : Planning is a vital managerial function, as it defines the goals of the clinic and answers the question "Where are we going?". We must treat our clinic as an organization with clear cut Goals and Mission statement. This will give direction to our efforts and help us to know our position at any given time vis a vis our goals and mission. This is the secret of an effective leadership ‘begin with the end in mind’. Men like to work for a Leader who is a source of strength for them. They like a leader who will build purpose and meaning in to their jobs. Staff members fail to carry out the action requested by the manager because he does not set the proper example. We must inculcate the spirit of leadership in each of our staff members and get him fully acquainted with the mission statement of the clinic. This way it becomes his own mission statement and his activities will be in tune with the overall objective of the clinic. My Mission is: "To achieve maximum patient satisfaction through adherence to ethics, systems and procedures. Continuous upgradation of professional skills through training and constructive interactions and dedicated team effort to enhance the commitment to improve quality and range of treatment at competitive professional fees, ensuring that the value of my treatment is much more than its cost."
Organizing and Delegating : Once our destination and direction are ascertained, then we have to find out how to get there. What activities are needed to achieve the agreed end. Whom to delegate what responsibility. The logistics and any other activities that will have to be undertaken to produce the desired result. We must sincerely try to find the goals and aspirations of our staff members.
The staff members should know that their individual growth is linked to the growth of the clinic. The manager must act as a bridge between the two goals. e.g. If the staff member wants to learn computers then the manager must encourage and accommodate the staff in such a way that he can fulfill this aspiration and thus prove to be an asset to the clinic in its future computerization programme. Many practitioners/managers end up at the wrong end of crematoria because they have not learnt the art of delegating responsibilities to others, feeling that others can’t do a good enough job, thus insisting on doing everything themselves. As a result unnecessary details, confusion and chaos confound them. They become victims of modern day scourge-STRESS. I am aware of the disasters that can result by delegating responsibility and authority to the wrong person. But hard as it is we have to learn to do it. If we don’t learn the art of delegation then there won’t be any time for creative thinking, planning or any other welfare or development activities. There was a time when I used to make patient’s case papers, write examination findings and prescriptions, collect blood, examine it, expose x-ray films and develop them, take ECGs and type reports all by myself. Today with the limited number of staff that I employ, most of these tasks are delegated leaving me ample time for corporate healthcare programme and for helping destitute children find a new lease of life.
Co-Operation : All of us have more faith in our own ideas than the ones shoved down our throat by others. Hence isn’t it wiser to make suggestions and let the other person think out the conclusion? I have LIVED this Dale Carnegie principle many times to effectively manage my new recruits in last decade. I call the staff meeting and ask them what exactly they expect from me. As they open up, I write down their ideas. Then I assure them by saying "I will give you all these qualities you expect from me. Now you must tell me what should I expect from you in return." Invariably the replies start pouring out "honesty, integrity, enthusiasm, teamwork, hard work, good behaviour with patients etc." Invariably the meetings have proved to be highly successful in raising the staff enthusiasm and the tempo of the work picks up. Once I live up to my part of their expectations, they are morally bound to fulfill their obligations. Consulting them about their likes is the right booster they needed. All of us like to be consulted about our likes, dislikes, wants etc. Make the other person feel that the idea is his and then see the miracle.
Accountability : Accountability is fixed when results to be achieved are delegated. Defining the results to be achieved is the first step in making people accountable. When people are not held accountable they become lax, drive and initiative are lacking. This leads to difficulties and ultimately to failure. In order that system of accountability should work satisfactorily, it must be tied in with the Appraisals of men and the compensation plan must encourage accountability. Otherwise this accountability system will fail. For this system to work effectively we must create a feeling of obligation, of trust and confidence in our staff members so that they consciously try not to let us down.
Supervision : For effective supervision we need controls. Without the controls, even the most astute Management By Objectives (MBO) will collapse like a pack of cards. We can exercise control by following methods. (a) Personal visits to different sections of the clinic, (b) Inspections, (c) Staff meetings, (d) Reports etc. The staff members are given the list in the beginning of each month and every day they tick mark the assignments completed by them. I check any tick marked duty at random and if it does not meet the standards, the respective staff is answerable. No one likes that situation. So they are always careful while marking the controls check-list. Another system that I have adopted is delegating among the staff members to supervise one another’s duties where possible. E.g. the Lab technician cross-checks the reports typed/printed by the typist before signing them. The typist maintains the income/expense accounts and the assistant doctor supervises this. The typist and the compounder supervise the housekeeper’s duties. The assistant doctor supervises at random the medicines dispensed by the compounder and ensures that the right medicines are dispensed. The assistant doctor or myself check the stock books once in a fortnight to ensure that the stock records are properly maintained and indented items have been ordered from the stockists. The assistant doctor calls the patients on the day before their appointments are due for vaccines/blood tests/x-rays etc. She ensures that the typist has already sent the post cards one week in advance. Once these tasks are accomplished, the respective staff member puts a tick mark in their control checklist/appointment diary. Glancing through this diary I know how the system is being followed by my team members. Occasionally I ask the patients if they got the reminders in time and when they compliment me for the same I pass on the credit to the deserving staff members.
Training : We must know that knowledge can be taught but skill can be imparted only by training. Skill is the art of transcribing knowledge in to action. For a medical professional it is utmost important that his staff members are skillful in their respective departments.
There can not be readymade training packages for different practice set ups. Each doctor has to decide upon his training module depending upon his professional needs, qualifications, areas of interests and of course his mission statement. I have adopted the TQM - Total Quality Management module for my practice and hence all my staff training is directed towards achieving this objective.
One good way of training our staff is to give them responsibility and full authority for smaller tasks and as they perform satisfactorily, assign them bigger operations. Training is a continuous ongoing process and at regular intervals we must assess the effectiveness of our training by way of mock exams or hands on testing of the staff in their respective fields of activity.
Motivation : A management expert has described motivation as motive in Action. For motivation to work, the job to be done has got to be properly understood for its successful implementation. ‘What is being done and why is it being done’ has to be explained to our team members.
Some managers think money motivation should be the right word. But the truth is though money is important, some times it can be counterproductive. E.g. Discontent with financial reward is a powerful disincentive but satisfaction with monetory rewards is not a positive incentive either. Greater the skills and professionalism of the individual, more sophisticated are the motivating factors likely to be. Hence besides money motivation, we must offer meaningful motivational incentives like achievement, recognition for achievement, job satisfaction, responsibility, advancement, mutual trust and respect.
Most of the lab technicians who have worked with me in last 18 years have joined me as naive, inexperienced freshers though qualified for the job. But I am proud to say that when they move on they are confident lab technicians, their self esteem is sky high, they have the distinction of having worked on automated instruments and are not scared to sit in front of a Pentium 3. Most important, even when they are not working with me, I can count on their assistance whenever needed!!
Teamwork : It is not enough to have individual good workers but they have to combine and co-ordinate in the team spirit to produce a professional performance. Each of our staff members must be made to understand that his area of operation has its own importance for the overall performance of the clinic. Once this is made clear then regularly this fact has to be reinforced to ensure that the staff member always remembers how important he is for the doctor and his clinic. In my practice whether it is the assistant doctor or the housekeeper, the typist or the lab technician, everyone knows the importance of his/her activity. This proves very beneficial for the inculcation of the Team spirit.
Human Relations : Long time back I read Dale Carnegie’s "How to win friends and influence people". Life’s meaning has changed since that day. I have endeavoured to master the principles in the book by applying them to my life. I have lived these principles. A chosen few principles I would love to share with my esteemed colleagues.
2. Begin with praise and honest appreciation
3. Make the other person feel important and do it sincerely.
4. Make the other person happy about doing the thing you suggest.
5. Praise the slightest improvement and praise every improvement.
6. Let the other person save his face.
Communication : Usually we take it for granted that communication is communicator oriented. This is why there is so much confusion and chaos all around. If only we understand that communication is effective only if it is receiver oriented. This is why the importance of getting a feedback from the receiver not only understands what has been communicated to him but also accepts it. Even though I have mentioned Communication as the last criterion I feel it is the most important factor in determining a manager’s effectiveness.
My Experience in management : Having received training in advanced motivational leadership, attitudinal training, management, Total Quality management and sales courses over last decade I have always endeavoured to apply to my practice what I have been trained for and what has appealed me. I would love to share with my listeners some of the simple management methodologies, I have adopted in my clinic and found to be very effective management tools. I am the first to arrive and usually last to leave the clinic, so the staff members make it a point to report on time. We enter our reporting time each morning in the Register book placed strategically on my table. Looking at one’s reported timings and comparing them with others is a good motivational key. The late comers or the absentees get a red circle opposite their name and no one likes to have this stigma. As a result, the overall attendance and punctuality is extremely satisfying. Of course I set the right tempo for them by being punctual myself.
I have always enjoyed having a daily staff meeting before starting with the patients. We have a silent prayer followed by sharing of good motivational thought for the day and a joke.
Each of my staff member has a diary. They write down the important tasks to be completed by them on that day. In case if I have a special task to be given then this too is delegated during the morning staff meeting. In the evening before they leave, the completed tasks are tick marked and sitting at my table I know the position of different work assignments in the key areas of operation, by glancing through the work diaries and duty lists of my staff members. The incomplete or balance chores are shifted to the next day’s work list.
The staff salaries are paid by cheques on the 10th day of every month. When the staff members join the clinic they are informed that it is against our policy to give advance payments or loans.
The policy of "Scold in private but appreciate publicly", works very well for staff motivation.
I am always open to suggestions by my staff members and wherever the suggestions satisfy my criteria, I implement them ensuring that the credit is given to the team member who suggested it in the first place.
Advantages and Disadvantages of the Practice Manager’s Gospel
1. Enhancement of staff productivity and morale.
2. Managed care helps us to improve our service to the patients.
3. Increases patient turnover.
4. Increases practice revenue.
5.Improvement in the standard and quality of medical practice.
6. Professional satisfaction to the family Physician.
7. Appreciable behavioural change in the manpower and cultural change in the organization.
8. Peer recognition.
1. Time and energy consuming.
2. You have to be willing to be a good pay master. Hence expensive.
3. Man power management is a continuous process and not just an end result to be attained.
4. Some staff members new to the concept may mistake your approach to be a weakness/softness. Hence continuous alertness is needed to rectify such cases.
5. Increase in the service charges of the practice.
6. Some patients may be lost to the clinic as their only criteria for selecting a doctor are his lower fees.
Here are few basic guidelines we should keep in mind while managing our manpower.
• Our manpower should be familiar with the clinic’s goals and mission.
• They must know what we expect from them and what is their personal contribution to the total effort.
• Each person must know what is his benefit by contributing his might.
• The goals assigned to each person should challenge him.
• Each person should know how his performance will be measured during performance appraisal.
• The doctor/manager should be an inspirational example.
The Mantra for Manpower Management for this millennium can be summed up thus:
• As we prepare for a totally service-driven practice by focusing on our patient, we must embrace the roles of our staff by promoting the concept of teamwork.
• Learn skills to maximize human and organizational resources for ever increasing daily productivity demands.
• Analyze our systems, cycles and processes. Recognize and reward service. Inculcate the spirit of principle centered leadership and the culture of human relations in our set up.
So friends, let us wake up to the fact that change is not an event but a process. With the entry of the Insurance companies into the virgin land of medical practice, let us gear up for the challenges ahead. Along with the fast advancing medical science and technologies let us understand the importance of keeping pace with the modalities of delivering the benefits of modern medicine to our patients with the helping hands, thinking head and a loving hearts of our well trained, enthusiastic, motivated and committed team of staff members.