This has been a topic of conversation lately. And while it may be fun to watch on Survivor, the gossip, taking sides, stirring of s@#$%t that takes place in a practice can be toxic and damaging. I dug up an article that Sandy Roth wrote a while back and with her permission, pass it on to you:
Triangulation and Forming Alliances: How to eliminate it
Why can’t we just get along? I suspect one of the reasons is that we don’t know how. First, the fancy definition: Triangulation occurs when one person, having an issue with a second person, takes that issue to a third person. Now for the street version: Triangulation is talking about people behind their backs.
Triangulation is a serious problem for many teams, and it can often get a group in big trouble. Although triangulation is a behaviorally immature approach to disagreement, many adults engage in it without understanding the full implications of this choice. When I observe this behavior, I ask about it. Often, team members are simply unaware of what they are doing. They have learned to gripe but not to address their problems directly; so they simply do what they have always done.
• Triangulation solves no problems
The only route to solving inter-team conflict is a full, honest and open discussion of the issues with every person’s active participation. All problems ultimately belong to the group and not a secret subset of team members. Here’s why. Let’s say Jeanne and Jane have a difference of opinion. When their individual efforts fail to resolve this difference and either party secretly takes her frustration or anger to a third person, that third person is now involved in a clandestine discussion. This unhealthy dynamic now “infects” the entire team. People always know who is mad at whom and who is part of a faction.
• Triangulation creates new problems.
Triangulation fractures the group by putting a greater emphasis on differences than on understandings. It almost forces people to focus on the negative aspects of their culture. Moreover, this strategy creates an environment of distrust and disrespect, which tends to undermine healthy aspects of relationships. Practice attention must then be shifted from patient care to team dynamics. What a waste.
• Triangulation creates false alliances.
Jane is angry with Maggie and goes to Susie to dump. “Have you noticed Maggie doing such-and-such?” Jane asks Susie. Now, Susie hasn’t noticed this, and initially she has no beef with Maggie herself. “No,” she answers. “Well, I have,” adds Jane. At this very point, Susie will most likely make a choice between aligning herself with Jane or standing in defense of Maggie. Susie will find it difficult to disagree with Jane. After all, Jane has come to confide in her — an act of “friendship.” And just because Susie hasn’t seen something doesn’t mean it hasn’t really happened. Human nature will more often result in a secret alliance between Jane and Susie against Maggie which is based on incomplete information and a pact to tell no one else. If she tells Maggie, she has violated Jane’s “confidence.”
The confidential information Jane has shared is now almost impossible to ignore. (Don’t think of an elephant.) Even if Jane drops the conversation at this point, Susie is now predisposed to seeing Maggie in the negative light of Jane’s characterization. She is now more likely see those things which confirm Jane’s picture of Maggie and selectively ignore information to the contrary.
• Triangulation encourages factions
Under the guise of “checking it out,” a team member triangulates with a third party (Sometimes this person is the dentist). First, let’s agree that this is tattling. If the initiator really wants to check things out, he or she can go to the only person who can answer the questions. The real purpose of this behavior is to gain allies. The more people who agree that you are right and the other is wrong, the stronger you feel and the more righteous you become. Once the number of allies begins to grow, the opposition is forced to counter. Before you know it, the practice is split and there is a full-scale civil war.
So what are the alternatives?
• Always go to the source
The cleanest way to handle any problem is to go to the source. Yes, this can be tough, but eventually the problem will have to be aired anyway and it won’t get any easier under the unhealthy circumstances triangulation creates. Forget about rehearsing, making sure you are “right” before you raise an issue or gaining evidence. None of these excuses justify triangulation.
• Never agree to keep triangulation confidential
If someone asks you to enter into unhealthy alliance by sharing secret information with you, simply refuse to keep it secret. The proper answer to “If I tell you something, will you promise not to tell anyone else? “ is “NO.” For what honorable reason would someone call your attention to a problem if she didn’t want some help actually solving it? If the real reason is to get your support in the civil war, refuse to be drafted. You can agree to help the person raise an issue, but you must never agree to be a secret-agent.
• Ask for facilitation if you need help
If a co-worker tells you about an issue she has with a team member ask the following: “How did you raise that issue and what happened as a result of your discussion?” Too often, you will hear that there was no discussion. At this point, encourage your friend to raise the issue immediately and offer to facilitate the process. Facilitate does not mean gang up. Facilitate means to insure that each party is heard and understood.
• Return the problem to the group if necessary
Of course the team needn’t handle every issue. But when reasonable attempts to resolve disputes prove unsuccessful, it is time to ask for support from the entire team before the relationship deteriorates needlessly. Be sure to ask team members to listen to the issues and avoid taking sides. The only side which matters is the onein the best interest of the practice as a whole and the patients whom you serve. Principles, core values and promises to patients matter. Egos must get out of the way.
We Need More Help at the Front Desk!
Why is it that team members in the non-clinical roles, often referred to as the “front desk staff”, complain about the amount of work they have to do and always seem to be stressed out? Here are a few of the comments we hear all the time:
“The people in the back don’t understand all the stuff we have to do”.
“How can I do the insurance when I keep having to answer the phone?”
“We never get caught up.”
“I’m constantly having to stop what I’m doing to take care of a patient. Then when I come back to it, I forget where I am.”
We have a couple of theories about the traditional front desk configuration and why it sets most teams up for failure.
THEORY 1: The front desk isn’t the area in which the dentist works. He or she doesn’t fully understand the challenges the staff is faced with and is less likely to know how the systems work against them, not to mention the outdated equipment and software challenges. For instance, many practices have only made a partial transition to paperless charts, making the practice dependent on two systems (paper and computer), which makes locating information more difficult, causing duplication and increasing the chance of error. The dentist rarely understands the challenges this poses for the team. (This is a subject in itself!)
THEORY 2: People who work in this arena often develop tunnel vision and have difficulty
seeing new ways to structure their work. The result is that the front desk staff keeps doing the same old things in the same old ways, and not doing any of them at optimal level.
THEORY 3: When the non-clinical staff complains long enough, the dentist usually breaks down and adds another person to the team to do the same things the other team members are doing, creating more confusion, more errors and even less efficiency and effectiveness – not to mention more overhead!
So, what’s the answer? Consider separating the tasks into two areas of specialty and assign the responsibilities to the individual who has the right skill sets. Let’s look at the responsibilities of the non-clinical staff and how those duties break down.
There are three distinct areas of focus in every practice – what we call the A-B-Cs :
Responsibilities that support the business of the business. They are related to paper and tasks – not patients. They can occur “behind the scenes” and in most cases, are not ones that must be addressed in the moment.
The key in this role: to be EFFICIENT with THINGS.
Just some of the responsibilities that might fall under this heading are:
– review chart entries at dayʼs end to balance against deposits
-insurance pre-authorization, submissions, review and followup
-opening and sorting mail with distribution to appropriate person
-entering payments from mail and over the counter
-printing receipts for patients
-monthly and annual closing and archiving
-organizing invoices and packing slips before matching to statements for payment
-payables entry in accounting system
-preparation of a/p report for dentist review and approval
-preparation of checks for dentistʼs signature
-mailing signed checks
-inventory of office supplies
-purchase of ofﬁce supplies and patient amenities
-errands as assigned
-maintenance of ofﬁce equipment and machinery
-computer system oversight and IT
-maintaining patient amenities (ie: coffee station, water, etc)
-hourly upkeep of patient washroom and reception area
-implementation of marketing, promotion
-communication and follow up with the lab
-communication and follow up with vendors
-planning continuing education
These responsibilities require focus, attention, detail, someone with self-direction and organizational skills -an analytical thinker. This same concept can also be applied in the clinical area of the practice – responsibilities associated with sterilization, operatory preparation, inventory and lab duties. They are all essential to providing patient care but occur independently of patient care.
B – Behavioral:
This arena has to do solely with the business of our patient’s business and is often the most overlooked area. These responsibilities often occur with patients and are focused on patient care, connection and communication. While some of the duties require planning and preparation, events often occur in the moment, can not be predicted and must be responded to in real time. This job requires an individual with big picture thinking. The best people are those with sensibility, grace, maturity, empathy, curiosity, good listening skills, confidence, good command of language, and the ability to think on their feet.
The key in this role: to be effective with PEOPLE.
The responsibilities that most often fall under this heading are:
-working with new patients from initial telephone call through treatment planning
-supporting patients in the moment whether on the telephone or in person
-urgency triage and establishing clear expectations with urgency patients
-maintaining oversight of patients in process – those for whom treatment has been
recommended but not yet completed
-organizing and managing the “lost souls” project – those for whom treatment has been
recommended and have dropped out of sight
-handling fees and ﬁnancial arrangement discussions that are not properly handled
-addressing patient complaints and issues in a timely manner
-ensuring that patient interests and concerns are clearly understood by all
-supporting patients by helping them price-test their treatment options
-ensuring that all patient-contact staff are prepared behaviorally for patients before they
-identifying patterns and trends with patients as they occur
-maintaining oversight of the schedule and making appointments as necessary
-managing patient correspondence and followup
-coordinating non-clinical aspects of care with specialists and referrals
-internal training on communications and patient relations
-connecting with referral sources, public relations, networking
C – Clinical:
Events related to the delivery of care. Commands most of the focus of the practice and is often the most up-to-date area. Requires the attention and oversight of the dentist/business owner. Removes the dentist/owner from constant oversight of the two other areas, making it even more important that self-directed, well-matched, highly-effective people are placed in the non-clinical roles.
As you can see, the non-clinical staff is responsible for two of the three critical areas of the practice. These staff members are often asked to perform both Administrative and Behavioral roles simultaneously while the responsibilities are very different from one another and require different skill sets. It becomes clear that when we ask them to assume both roles, they are split between two very different responsibilities, making them choose in the moment which is more important. This usually creates more problems, and sets them up for failure, making them less effective or efficient in either of these areas.
It is our opinion that when you separate the Administrative from Behavioral roles and hire/assign responsibilities based upon strength in one of these two areas, you encourage deep competency, similar to your competency in the area of dentistry. Each person performs at a higher level when they are focused on only one arena and they become more successful than if they were asked to do everything with less effectiveness.
This is not to say that a person who is assigned administrative responsibilities can’t support the one who is responsible for patient connection by answering the phone, welcoming patients or checking patients out when necessary. There are always exceptions. Some practices opt for a third person to act as a greeter or to handle phone triage and appointment scheduling. Remember, the goal is to encourage deep competency in their skill set and prevent team members from performing in areas where they are not as skilled.
This concept may require you to think differently about the individuals, skill sets and responsibilities in your practice. A good exercise for each of your non-clinical team members is to have them make a list of their duties and determine whether it is administrative or behavioral (we hope you aren’t asking them to also perform clinical roles too!). Ask them to assess how much of their work load is in each of these arenas and discuss how roles might be shifted to better serve this new model.
Take home message: You most likely don’t need more people serving in a non-clinical role – you just need the right people, with the right skill sets, in the right positions, which creates a better, more efficient and effective systems.
A caveat here – you may discover that you have team members who share similar skill sets leaving you with no one to serve an administrative or behavioral role. This may be the eureka moment that explains why certain problems keep occurring in your practice. This process may also cause you to consider restructuring your non-clinical staff altogether. We can help you consider your options and sort through the implications of making changes to better serve the practice and your patients.
Help! My Staff is Holding Me Hostage!
The voicemail message sounded desperate. “Call me back as soon as you can. I need your help right away!”
What caused such distress? What made the situation so urgent? As it turned out, the dentist was having difficulty keeping a chairside assistant and was faced with hiring for the third time in less than one year. His receptionist had left but he wasn’t happy with the performance of her replacement. Each day brought another drama with the hygienist whose personal life was in total disarray. The practice was totally unstable and he feared losing another employee every day. What would his patients think when every time they came in there were different staff members?
After a short discussion, it was quickly clear his staff was calling the shots:
“My hygienist didn’t show up for our meeting yesterday and didn’t even offer an explanation. We are constantly bailing her out of personal situations. I know it’s hard for her – she’s a single mother and doing the best she can. Then, my chairside assistant refuses to do things that are part of her job. I end up having to pick up the slack at the end of the day before I leave. I overheard them complaining in the lab today about a continuing ed program I was paying for them to go to on their day off. They joked that they would just sit in the back and text on their phones. I’m afraid to lose them because our patients seem to love them and I’d have to spend time breaking in new staff but I don’t know how much longer I can go on. I feel like a doormat”.
While this scenario may vary from one specific practice to another, the problem is basically the same in many: dentists who neither know nor enforce their boundaries and expectations because they are afraid they may lose staff. Indeed, their staff is holding them hostage. How does it get to this point?
Let’s examine the factors that contribute to this phenomenon:
1) The dentist’s personal relationship with staff makes it awkward to set and maintain standards and/or fire a low-performing employee
While we all have busy, challenging lives that can effect our professional lives, these issues should never dictate office policy. This is an area in which many dentists confuse their personal relationship with their work relationship. It stands to reason that because you work together closely all week, you might easily develop a strong bond with one another. You may find yourself identifying with your staffs’ personal problems, like managing a home and family and trying to make ends meet. Express your empathy, of course, when appropriate, but as an employer you must establish clear boundaries. Do not advance paychecks, pay rent, loan cars, or pick up kids. Do not make concessions for days off outside a very rare and unavoidable situation. By doing this you will set a very dangerous precedent. Other employees will consider it favoritism and they will expect you to afford them the same concessions.
If you have already “let that horse out of the barn”, you can reverse this trend. Gather your group together and apologize. Explain that you care about each person on the staff and this has clouded your judgment. It has created a problem for you and others. You must now establish a new set of boundaries that are in the best interest of the practice and your patients. Then you must outline where you went wrong and what you are no longer willing to sponsor. They may not like it but they will understand.
If you believe your personal relationship with an employee has gone so far that the two of you can no longer be effective working together, give us a call. We can help you sort out what the appropriate next step should be.
2) Even if it’s written down in the manual, not every employee will know what’s expected and will follow through.
Your employee manual means nothing without two things. First, your staff needs to understand the bigger picture. It is your job to clearly convey to each person what your practice is there to accomplish and how their efforts are expected to help make that happen. The big picture is crucial. More than the step-by-step guide that a manual provides, your explanation of the practices’ purpose, as well as your beliefs and tangible examples of how this purpose is played out on a daily basis is vital. It will give them a guidepost to follow in their day-to-day challenge of making decisions about what is in the best interest of the practice and the patients.
Second, every employee must be on board with your purpose. Each must be in alignment with your belief system and share the same basic values. And you must have their agreement about their role and responsibility. This can best be accomplished as a group discussion where each staff person has an opportunity to ask questions and gain perspective. Time consuming? You bet. But without this clarity your staff will be working without a clear direction which often works at cross-purposes with the practice goals and will cause a great deal of frustration for everyone.
3) Hiring and training the right way often takes a back seat to retaining under-performing staff.
A good way to think about your problem employees is the bad girlfriend or boyfriend you may have had. You knew long before you broke it off that things weren’t working out but you avoided it hoping things would get better. They rarely do. Then, when you finally got up the nerve to end it, you thought to yourself, “I should have done this a long time ago”.
Your under-performing staff are robbing the practice. Pure and simple. You simply can’t afford to work with people who are inefficient, ineffective, and cost your practice time, money and resources. The focus and energy these employees sap from your patients and practice deprive you of much more. You can not be as effective in your job when you are worrying about staff doing their job. It stands to reason that the under-achievers aren’t dedicated to your practice purpose and patients are not receiving the same care and attention you strive to provide.
While hiring and training (and doing it right once) requires time and energy, doing it over an over again takes you away from focusing on dentistry. And it’s not a lot of fun. Cutting your losses and embarking on the hiring process can be an opportunity to make a course correction. If you approach this process correctly, you will avoid having to carry dead weight on your team. You will have a solid and stable group of individuals for a longer time. Approaching the hiring process correctly is essential.
You can bring your new hires on with a strategy for success that includes a thoughtful training plan designed to help them succeed. Equally important are periodic evaluations (for everyone) to keep your team performing at a high level, stay motivated and focused on the big picture.
There are way too many dentists “making do” with staff because they are afraid they won’t find a better replacement. While high-performing employees are more rare and difficult to find, they are out there. It is just a matter of knowing where to find them and how to attract them. They may be disenchanted with their current job or looking for a greater challenge or more responsibility. Perhaps they don’t feel they are appreciated or they deserve more compensation for what they do. Those are your candidates. It just requires more diligence on your part to find them. It takes a dedicated effort, creativity, and a solid plan to attract that exceptional staff member. It starts with an exceptional ad that is masterfully written and trying new and innovative strategies to distribute your ad. Most practices do a lousy job at this and dread the process. The pool of candidates often reflects the quality of the ad, which often misses the mark.
Are you being held hostage? Stop letting your staff dictate what happens in your practice and take control. If you believe it is a matter of establishing clear boundaries and re-establishing expectations, start the process today. You can no longer afford to allow this to go on. If you know in your heart that there are one or more staff people who would be better off somewhere else, start making plans today to embark on the hiring and training process.
Of course, we can help guide you through this. We can help you clarify where you need to make changes and develop a thoughtful process for implementation.
If you plan to hire, consider calling on us for support or using the tools in our hiring kit. You can learn more by clicking below or calling us at 800-848-8326.