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Up Front | May 2008

The Administrator Crisis

This position will enable a practice to succeed, or hasten its failure, in the coming years.

Something bothers me each time I speak at a conference or visit with attendees after a training seminar. This small seed of doubt has become a full-blown concern. We have a partnership crisis looming in ophthalmology, and it is not the association with the doctor. It is an administrator crisis. I have been an administrator, a refractive center's director, an office manager, and a refractive coordinator—all of which are titles for an individual who stands alongside a surgeon in practices of various sizes and manages everything but the doctor/patient encounter. I have hired for and trained others for and sometimes terminated this position. What I know is, I am worried.

In my opinion, ophthalmic administrators are not fulfilling their responsibilities. They are your partners. They make things happen and ensure practices are profitable. Most importantly, however, administrators must be patients' advocates, especially when a surgeon's and staff's behavior conflicts with superior patient care. Administrators build bridges between financials, facilities, patients, and staff. More often than not, administrators work for demanding surgeons with strong personalities. The resulting friction can wear an administrator down so that she is no longer the effective partner you need.

Many administrators stop saying "no" to you, even when "yes" is unlikely to occur. They stop welcoming change and innovation and instead offer placation. They react to daily challenges, rather than proactively shape a practice's future. As technological innovation alters clinical offerings, and demanding consumers fill appointment calendars, the administrator is often uncertain of what is required of her in her position. In my view, administrators represent the single biggest opportunity for, as well as an obstacle to, improving a practice's future performance.

In his excellent Little Green Book of Ophthalmology,1 John Pinto includes a chapter titled, "Helping Your Managers Manage." In it, he outlines several characteristics of an excellent supervisor. Key, in my view, are a direct knowledge of the job, an "action today" orientation, adaptability, grace under pressure, accountability, strong communication skills, and a disciplined "tough love" approach to both employees and physicians. I have found these traits to be vital but often missing in the administrators at practices struggling with growth.

My area of expertise is in expanding elective services within a practice, which generally means growing LASIK and lens surgeries. I have found, however, that improving the elective offerings of a practice changes its insurance side as well. Flow improves, and patients wait less. Their satisfaction improves, because the in-office experience and surgical result are optimal. Staff morale improves, and turnover decreases. Profits grow. These changes, however, require an administrator who functions as your equal and as a true partner in the delivery of care.

You groom your administrator to be your advocate, but an administrator must be a patient's advocate in order for an ophthalmic practice to grow in the future. Administrators must have the authority to create and adjust patients' experiences. This means improving these professionals' training in:

  • creating and maintaining a pleasant office environment, including public and clinical spaces;
  • determining and implementing an optimal appointment template so patients do not have to wait;
  • improving customer service, counteracting apathy, and diffusing conflict between patients and the staff; and
  • understanding what testing and staff interaction are required at each visit by a patient so that the accuracy and experience can be improved.

A great deal of your administrator's time is spent keeping you happy. This usually involves moving patients on the schedule, changing or eliminating clinical days because you want to be out of office, and smoothing rough exchanges between you and your staff that result in hurt feelings. None of these activities improves the patient's experience, nor does it enhance a practice's profitability.

Administrators often take a hands-off approach to clinical processes, when these are exactly the areas that require patient advocacy. An administrator should ask the tough questions. Why do we test that way? Why is the equipment located in three different rooms so that patients must move? Why does each physician use a separate evaluation form or informed consent or drug regimen?

Patients perceive the practice as a unified entity. It is the administrator's job to make that perception a reality.

You train the administrator on how you want patients sequenced, but the schedule rarely runs smoothly. There are too few technicians or staff members available to offer assistance. Sometimes, inconsistent charting or a backlog at the testing bay occurs. Does your administrator understand the intricacies of appointment templating, which drives the entire practice's operation?

When physicians and staff reach their physical limit of patients per hour, it is time to fine-tune the art of scheduling. Administrators must know how to evaluate whether the practice is seeing enough patients and the right mix of patients as well as whether they are under- or overutilizing personnel and locations. Too often, I have seen administrators throw up their hands and say, "That's how the physician wants to see them." This is not advocacy but rather abdication. A good administrator understands the leverage within the practice and can build a financial case for why change is necessary. She persuades you with facts, and you respect her focus on patients' and the staffs' satisfaction and the practice's profitability.

When was the last time you invested in training so your administrator understands the template and its intricacies? Is this training available? Is the administrator willing to tackle these emerging issues? How familiar is she with Excel (Microsoft Corp., Redmond, WA) and scenario analysis so she can present you with a studied evaluation on whether shifting out of glaucoma, adding another optometrist, or working late one evening each week is warranted. This is where your administrator can stop the churn and enhance productivity.

How financially savvy is your administrator? Does she understand the levers on the practice's income statement, surgical outcomes, patients' satisfaction, and conversion of inquiries? Does she know how to reduce the cost of patient financing? Does she know where problems lie in your accounts-receivable aging? Does she know how to adjust employees' compensation so it becomes a variable expense, rewarding both you and your employees for growth while minimizing the practice's risk in a downturn? I always ask, "How can we know we're winning if we don't know the score?"

Good administrators are analytical. They keep score. They provide fact-based determinations about hiring and investing and expanding. They do not simply do what you ask them to do. They advise. You tend to remember the last cornea you saw, the last unhappy patient who sat in your chair, and the last incomplete chart you opened. In addition, you sometimes request a new rule to deal with that instance. It is your administrator's job to provide you with accurate analyses of trends, not exceptions, to help you make the correct decisions for the majority of the practice.

The root of the matter is you need an ophthalmic administrator who leads. Practices that are struggling to grow, find the proper work-life balance, deliver exceptional care with commensurate compensation, and create an exemplary workplace need a solid physician/administrator team. Physicians are not trained in the business of effective practice building. Interestingly, I am not sure complete curricula for both insurance and elective vision services exist for administrators, either. A great administrator, especially in a practice of one to five physicians, should be an entrepreneur. She knows how to hire, delegate, and lead. She knows what issues warrant her attention and how to get your attention in order to benefit the practice. A great administrator serves the entire practice.

Jim Collins' book Good to Great2 challenges readers to get the right people "on the bus" and put them into the right seats. If you are going to address administrators' leadership skills, you must ask yourself whether you have the right person on the bus. In addition, you must be truly objective about the seat in which you have put her. Does she have the skills? Can she learn them? Do you want an administrator who can and will stand by your side in a true partnership? When you address these issues, you will grow your practices, profits, and personal satisfaction.

Kay Coulson, MBA, is the president of Elective Medical Marketing, a consulting firm based in Boulder, Colorado, that helps surgeons grow their elective vision service lines. Ms. Coulson may be reached at kay@electivmed.com.

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