How's Your Office Manager Doing? Don't Let Question Just Hang There

MANAGED CARE November 2000. ©2000 MediMedia USA

Every worker needs a performance review at least once a year. So, who reviews the reviewer? You do.

Jeffrey J. Denning

Every practice has someone in charge. It may be an executive-level administrator, a seasoned office manager, or a "lead" employee who works without the title. Sometimes it's the doctor. There's a lot to the job, and not everyone does it optimally. Look for these signs and symptoms that indicate your office manager needs improvement.

In our practice management consulting work, physicians repeatedly tell us what they want in an office manager: lower overhead, a smooth-running operation, and fewer personnel problems. That's a pretty good summary. We look for someone who will collect agendas, implement decisions, and solve problems. Good office managers set a good example for the staff. They listen to patients, employees, and physicians. So, is a bad manager the flip side of all this? Yes — and worse. Here are three warning signs to watch for.

"Need-to-Know" security clearances

Computers are not too complicated to be understood by physicians. Accounting reports are usually pretty straightforward, too. So why are the procedures and information in the business office so mystifying?

Insecurity bordering on paranoia often accompanies incompetence. Bad managers have to keep the boss in the dark or they will be exposed. They do it in subtle, sometimes passive-aggressive ways. When the boss asks why unpaid accounts-receivable is so high, they hand him a 212-page printout. Raw data are not useful; they need analysis to become the answer to a question. When the physician learns of repeated billing or scheduling problems from colleagues or patients instead of the manager, it's embarrassing evidence of manager problems. If you feel that you're flying blind, it may be time for a better navigator at your side.

Serial employee turnover

Finding the right person for each job is a little like shopping for shoes. You can go through several pair before you find the ones that look and feel good. It's especially distressing when you're replacing your favorite sneakers and they've discontinued your model. Losing good employees hurts the same way. When it happens over and over again, there's something wrong.

Under the supervision of a bad manager, your most productive, sometimes senior, people can become malcontents. It can come as a sudden resignation without the physician ever having been aware of a problem. Bad managers are often insecure, preferring to deal with less skilled (and less threatening) employees. They frequently oversupervise, meddling in the work with criticism. Good people, who have the know-how to do the work, grow weary of it and can easily find better places of employment.

A chain-of-command structure is helpful: All employees are instructed to deal with their direct supervisors — usually the office manager. However, when the office manager irrationally refuses the employees access to the physicians, it starts to raise doubts. Secure managers don't need to throw up an impervious wall between the staff and doctors.

Physicians feel trapped

"We can't fire her, because she's the only one who knows what's going on around here." "She may not be the best, but she keeps our books at her home — and I'm worried about their security." "It's such a hassle to look for another manager, and we would never be able to find or afford a pro."

Good managers become valuable, not indispensable. They keep their backups trained and delegate plenty so they can take on new projects. When managers make themselves indispensable, it's a sign that there may be quality problems.

Of course, these indicators of trouble may not be fair, taken out of context. Every manager needs a thorough and fair performance evaluation.

Many practices avoid reviews because, like their employees, they think it's as much fun as a trip to the vice principal's office. Maybe it's time for an attitude adjustment on this subject.

One reason manager reviews are avoided: This is the one review your office manager can't do. It has to be done by the physicians. Since many physicians are concerned about upsetting the status quo by offering criticism, they avoid manager reviews. They may also withhold praise because they think it will lead to a manager demanding a raise. Finally, individual physicians in group practices may be unwilling to conduct an unfavorable review for fear that the manager will somehow "get even" with them for criticism by favoring another partner. All of these reservations stem from a negative view of the purpose of reviews that goes all the way back to our first report cards. So, emphasize to your office manager — to all employees — that the objective is to improve performance, to help employees become more valuable to the practice. Explain that it is through this process that employees earn raises.

Another complicating factor: The job of the office manager is often less specifically described than those of other workers. A good manager is often characterized by the absence of problems in the practice. Depending on your attitude, managers could always be in trouble by that criterion.

Ask yourself some of these questions so you can prove to yourself that you've done a thorough job.

Are you better off now than you were a year ago?
Did the manager help or hinder your practice?
Do you feel in control?
Has your manager earned the respect of the staff?
Does the manager inspire your confidence?
Are you comfortable having this manager represent you to the public?
Does your manager get you to make all the decisions?
When necessary, does the manager stop you from embarrassing yourself?
Is he or she exhibiting any creativity — new ideas, innovative problem solving, morale boosters for the staff?
Do you understand what your manager is telling you? Does the manager understand you?

Now, these questions are just meant to get you thinking about big issues — trouble spots and areas of success. It might be unfair to hold your manager solely responsible if you're not better off this year than last, for example. With this overview, however, you will be in a better position to get down to specifics with your manager.

Valid manager standards

When it comes to the review interview, work from your manager's job description. Give a grade to each element of the job. If there isn't a job description for the manager, ask him or her to write one for you both to use. You may want to follow our example to get started.

The nature of the job will depend on the size and type of practice. Those with only a few employees will have the manager performing more day-to-day tasks and less actual management. For a practice with more staff, the manager's job description begins to take on an administrative orientation.

The clearer the job description, the easier the task of evaluating the performance. For example, if your payroll used to be 15 percent of collections and now it's 19 percent, what's the reason? How was the employee turnover during the year? If you lost good people, could the manager have prevented it? Are you dealing with too many employee problems yourself? Is the manager setting a good example for the rest of the staff?

The physician's job is to produce the billable charges. The office manager's job is to collect them. So consider the financial section of the manager's job description. Our example calls for accounts receivable to total less than three months' gross charges and a specific minimum acceptable gross collection percentage. While it's easy to grade the performance, remember that the issue is how to improve the performance no matter what the grade. Go into the review with the facts available and come out with an agreed plan.

As hard as it is to sit down with your office manager to discuss performance, you need to steel yourself to the task for three reasons. First, like the rest of us, good managers want to get even better. Your help in the process is a motivator on the job. It proves you care about your manager's contribution to the practice, a form of personal and professional validation.

Second, you need better performance from every worker each year to stay competitive. That includes your office manager. Who is in a better position to help your manager improve than the boss?

Finally, it's just not fair to withhold feedback. Managers who are fired without any documented attempt to correct problems may have justified claims of unfair termination. A judge or hearing officer may make you regret your hands-off style.

The fairest way to evaluate the manager is against a published job description. If the office manager has participated in the drafting of the job description, so much the better. Together, you should have a list of the manager's goals for the next year by the end of the review. That will make the next review easier, too.

Don't be a do-it-yourself manager

When practices get rid of disappointing office managers, the process is sometimes so upsetting that physicians are tempted to make do without a replacement. "Think of the money we'll save," they rationalize. Mostly, they are just denying the good reasons they had for hiring a manager in the first place. Avoidance of further failure is a powerful motivator for many physicians.

Nevertheless, it's frequently a mistake to quit trying to use a hired manager to run things in all but the smallest practices. Managing a medical practice isn't easy. It takes training and experience — and hours of close attention. Few physicians are willing or able to bring those attributes to the task. The results show up big time.

The doctors leap into the breech, sometimes firing from the hip. They make personnel policy decisions ad hoc, without regard to the applicable laws. Or, they transfer the employees to a personnel leasing company, expecting it to be responsible for supervision. A doctor's spouse takes over the confidential work of paying the bills and preparing the payroll — badly — and feels indignant when no one offers to pay her. Who tells her it's not working out?

In a group, one physician may lobby to be the managing partner. Watch out. Wanting the job is a good indicator he or she shouldn't have it; it's irrational for a physician in private practice to want to be an office manager. Frequently, he or she also expects to be paid for the job. That's fair, but overlooks the fact that you don't pay physician wages to office managers.

When physicians take on administrative duties, they lose valuable billable or personal time if they are really working at the job. If they are not, things can go to worms fast.

Because of limited time and lack of experience, physicians may not inspect the audit controls in the office as often as a hired manager would. They can easily be stung by dishonest or, more often, incompetent workers. It can cost tens of thousands of dollars in unrecoverable billings before it comes to light.

When the doctors are the primary contact for personnel issues, they can expect a constant parade of employees backbiting and informing on other workers. When the employees are essentially unsupervised, they wind up supervising each other, creating conflict in the office. Office politics runs rampant, with workers jockeying for favor with the physicians. Problem employees are often left in place; work, morale, and patient satisfaction suffer.

No, the "do-it-yourself" approach doesn't save money. The problems will probably increase.

Jeffrey J. Denning is a practice management consultant in Long Beach, Calif., and the editor of the newsletter Uncommon Sense. He is a member of Managed Care's editorial advisory board.