Ok, so congrats!
Ok, so congrats! You gone through (various Coleman offerings) and you’re starting to see patients! You’ve embraced the Sheep/Shepherd model to its fullest extent. You used to run your practice, run flow, and, if we’re being honest, run so many things it made it hard for you to do your job, let alone get home on time. You now trust your support staff to get you to lunch on time and home to see your friends and family. You’ve been trained to not look at the schedule (it’s never accurate anyway with no shows and walk-ins added); when you walk out of an exam room, you’re greeted by your assistant, who asks you if you need anything, tells you who’s arrived, and tells you what to do next. Your team have become QuickStart experts, and patients smile when they see you instead of looking put out. Oh, and did I mention: your rooms are STOCKED all the time! You’re disciplined in your charting approach, making sure you finish your charts and your labs by the end of the day, so work and home life don’t blur. You feel rejuvenated. Finally!!!
But that was 6 months ago. That initial rush you had–that team feeling–it’s slipping. Your cycle times are still ok, but are creeping in the wrong direction. You still get to lunch on time (mostly) but by day’s end you feel hectic again. You can’t put your finger on the cause, but you don’t like experiencing the old feelings of burnout, frustration, and fatigue, and you’ve had a few days like this recently. You did some charting from home the other day–ugh. You find yourself doing things you used to do, like schedule watching and telling your assistants what to do (in other words, you are the Shepherd and Sheep). You feel tempted to go back to the way things used to be, but it’s such an odd thought/feeling because you know that doesn’t make sense…you were miserable before
Happily you don’t have to go back. Here are a few rules of thumb to get you back on track.
Before you start to try to fix your team, make sure you fix yourself. You’re likely the only person on your team with a medical license and, like it or not, your team will follow your lead. This absolutely plays itself out in your clinical day in not-so-subtle ways. If you show up late for huddles, your team will as well, and before you know it huddling becomes unimportant. The same goes for Visit Prep, Red Carpeting, QuickStarts, and 30-Second Reports: your team senses that they don’t matter to you, so they won’t matter to them. It’s a very slippery slope because Coleman concepts are interdependent; each step sets the next step’s success. For example, deemphasizing the need for a Robust Visit prep diminishes huddle quality, and that in turn hurts QuickStart efficiency and 30-Second Report quality. As team leader, make sure you CONSISTENTLY emphasize how important all the steps are for your team and for your patients. Consistent attention to detail and specific praise for team members who meet or exceed expectations produces results. Likewise, inconsistent messaging produces mixed results at best, and more commonly initiates an almost domino-like regression back to the old days.
Rule # 2
Set and maintain expectations for your team. Implicit to the Shepherd/Sheep model is that your team is, in a sense, your boss. Your assistants are charged with running your day, whether it involves Visit Prep, strategizing who to see and when, or Jockeying your Schedule, and the Shepherd/Sheep model working at its peak means you will exit an exam room asking your assistant, “What do you want me to do next?” and then doing that thing. Being a clinician’s Shepherd is often a confidence boost for your assistant. For many assistants, prior to Coleman, primary tasks were confined to vitals and rooming patients, maybe checking some labs, and getting reports– nothing too difficult. The Shepherd/Sheep model elevates your assistants’ clinical role to that of manager, with absolute responsibilities and expectations. What was primarily a “do” role (room, get vitals, etc) has been expanded into more than that, as it now requires real-time problem solving and thinking. Generally speaking, becoming a valued and trusted team member is a source of pride for many assistants, because they went into healthcare for the same reason you did: to make a difference in people’s lives. Given all that, when you fail to hold your team accountable for performance, it suggests that their role isn’t vital to your team’s success and, at the very worst, you’re implying they don’t possess the skill or intellect to Shepherd you. Often clinicians will withhold specific tasks from their assistant thinking, “I don’t want to burden her”. Admirable, but you may also be messaging, “I don’t trust you,” therefore undermining her confidence and hurting her job performance.
Rule # 3
Give direct praise for the behaviours you value. Unfortunately the words “awesome” and “amazing” dominate healthcare today. If a clinician and assistant have at least an adequate work relationship, performance of routine tasks are characterized as “awesome/amazing”. Let’s say, for example, visit prep was done well (or done at all–clinicians will often say what an “awesome/amazing” job her assistant did, when in fact her assistant was performing her assigned task, as is required by her job description. The clinician in this example thinks she’s providing valuable feedback, but in fact it’s vague, overstated, and problematic. An assistant might think, “If I’m awesome for doing what’s expected, what am I when I make a mistake or I’m having an off day? What’s the opposite of amazing?” In that way, awesome/amazing feedback can create a rollercoaster work experience for your assistant–one day great, another not so much. Providing direct praise for the behaviours you value avoids this trap and allows your assistant to build a skill set. Instead of “awesome/amazing chart prep today,” say, “When you review the plan from the last note, it really frames and gives me direction for this visit. Good work!” Now your assistant knows to include this in her report for every visit prep! And that’s how you build your assistant’s skill set: with direct feedback about what you think is important– until you don’t need to ask for anything anymore as your assistant will know what you value and provide it to you without asking. One last word about awesome/amazing, though: if you feel the need to use these words, reserve them for special occasions. Some clinicians like to use this type of praise around difficult-to-see patients that fulfill their organizational mission, wherein assistants are providing a “going above and beyond” type of care. Lastly, some clinicians save this praise specifically for clinical consistency, acknowledging that any team can have a good day but that putting together six months of mostly good days is difficult and requires daily attention to task and professionalism.
Ask for help. Sometimes, when you’re embedded in a situation or a system, it’s difficult to see or make sense of what’s going on. In the same way you would send a patient for a consult or a second opinion, have either an internal coach or a colleague who is Coleman proficient come observe your team and provide feedback. If you go this route, make sure you talk to your team about it beforehand, otherwise, it can be interpreted as a comment on job performance, rather than as an opportunity for professional growth.
You got where you are now, as a practicing clinician, through study and practice, and it took a considerable amount of time to get good at it. Clinic processes works in the same way. Read articles about it, talk to your colleagues about it, and try to get better at it every day. Seasoned clinicians will acknowledge that they mostly see the same diagnoses every day, and at least from a medicine perspective, they have it down. Days have long passed since a HbA1C was interesting, or treatment for this or that problem was a mystery. These clinicians derive job satisfaction from predictable, consistent days, and by providing much needed access to their community. Use these rules to make sure that this happens consistently.
By Tim Spurrell, M.D., M.Ed.