From Doctor to Impactful Leader: Scaling Your Practice

Brent Lacey, M.D.

Cheng, it’s gonna be awesome. I mean, what a great topic for a summit like this, ’cause I mean, as much technology as you may have as many things as you have to automate the process and simplify your life, if you don’t have a good team behind you, if you don’t have a good culture, if you don’t have a good organizational concept, then none of it’s going to matter. So this is a great, great topic for us to be talking about.

Cheng-Huai Ruan, M.D.

Yeah, so I was talking to one of my friends, who’s actually an office manager and I was asking, “Hey, how’s your like company culture over there?” And he’s like, “Well, we’re mostly Hispanic.” And I’m like, “That is not what I’m talking about.” I wanna start with culture and then jump into leadership because I think they kind of go hand in hand. But Dr. Lacey let’s define, what do you think company culture is? What is the culture?

Brent Lacey, M.D.

So it’s gonna be a different framework for everyone. But the basic concept of the culture is what is the, the general feel of the organization. It encompasses what’s the mood, what’s the standard interpersonal dynamics. What’s the typical relationship. What is your extracurricular activities? And so it encompasses a wide variety of things. So it’s how do the staff interact with each other? What kinds of values do you share? What kinds of things do you celebrate? For what activities and what character traits and what work-related accomplishments do people get promoted? It’s the things that you choose as an organization to inculcate in all of your members and then celebrate when you see those values and those character traits and those qualities exhibited by your members.

Cheng-Huai Ruan, M.D.

Absolutely I think company culture is a make or break. I think that it starts with leadership and it ends with every person that is part of the company. And so in the company culture, developing a really core common culture is not easy, especially in the medical climate and medical community. And there’s such a huge turnover in employees and that turnover can detriment a company culture if the leadership allows it. And so my definition of company culture is just as you said, is the feeling of the company, but it’s also the direction that unifying body and the direction that’s required for a company to move as a unit, but at the same time, you want everyone to be all in. So I like to call a sort of the all in culture, because that translates to how we speak to patients and how we speak to each other as doctors and stuff like that. And so, and this is instance is a fabulous topic, but let’s talk about a company culture and how to get to where we want it to get to. So what do you think are some of the core components of building that good team and a good culture?

Brent Lacey, M.D.

So it starts, I think with hiring the right people, you have to have the right team. And so there’s a saying in the culinary arts. And so if you’re a chef you’ll hear people say things like you can’t make a good meal if you don’t cook with the right food. And so if you don’t have good ingredients, if you don’t have, good meat, good vegetables, good spices, you’re not gonna be able to produce anything of value and quality, no matter how much training you have and how many stars you have behind your restaurant, you need to have the right people in your organization. So one of the books, there’re two of the books that I recommend people read, if they’re gonna be in business, or if they’re going to be in leadership are both by a guy named Jim Collins one is called, “Good to Great”. 

The other one is called “Built to Last”. And in those books, he describes a series of very important concepts for any business leader. And one of the things that he talks about is the idea of getting the right people on the bus and the bus being an analogy for your company. So you have your company, it’s like a bus, and you’re trying to take it from point A to point B. So you need the right people on the bus. You need the right people in the right seats on the bus. And need the wrong people off the bus. And so that all starts with the hiring process. So you wanna have good people on your team. 

You wanna have them doing the roles that they were meant for like roles that actually utilize and showcase their unique talents and gifts in a way that is beneficial for the organization. And you have to get rid of the people that are dragging the culture down. So bringing the good people, get them doing the right thing, and then get rid of the ones that are not meeting it. And then I think the second thing that you have to do is you start from day one with your onboarding process. And as I’m saying this, I guarantee you that between a third and two thirds of the people listening are saying, I don’t think we have an onboarding process for our team members. And especially if you’re in a small practice, it’s very normal. So maybe you have maybe your onboarding process may be as simple as the office manager is gonna take them to their desk and show them here’s your phone, here’s how you dial for an outside line, good luck. That’s very, very common, but I think it’s very important if you’re going–

Cheng-Huai Ruan, M.D.

That’s like residency man.

Brent Lacey, M.D.

Oh straight up. Yeah. And so I think it’s very important if you’re going to have a culture that is permeating throughout the organization, that is a positive influence on your company’s direction. You’d have to start by really instilling those values and coaching people as they are coming on to your team. And then I think the third piece of it, is the consistent daily grind and the consistent weekly staff meetings, and the consistent monthly staff celebrations, however you wanna do it, but consistently recognizing the cultural values that your team members, your employees exhibit, and then celebrating those and promoting those and being excited about those. At your weekly staff meeting, it’s like, one of our company values is relentless optimism. And here’s how I saw Susan showed that this week, and we’re celebrating Susan, but we’re also celebrating the value. So you gotta get the right people, you got to get them doing the right job. You got to start instilling those values, those cultural values when they onboard. And then you got to keep promoting those and imbibing those on a daily, weekly, monthly basis. That consistency is gonna be really key.

Cheng-Huai Ruan, M.D.

You know, that’s hard. And I think it’s part of the reason it’s hard because that’s not how we were chiseled out of rock in residency and fellowship. And I think that culture is not really talked about in medical training. It’s very much of a hierarchal approach, but in business, it’s not necessarily like that. And if you try to treat a business more like an educational institution, it can potentially fail in a not so great way. And so, we talk about, having the good ingredients, getting the good people in. Like what is good? Like how do you know what’s good? Like, what is your definition of good? Do you particularly have a screening process for people on your staff?

Brent Lacey, M.D.

Yeah absolutely. It’s a great question. So there’s two basic ideas that I think you can select for, when you’re trying to hire somebody. You can hire somebody for a fit of their skillset and then you can hire them for a cultural fit. So for example, so I’m a gastroenterologist. So let’s say I’m looking to hire a new junior employee. So I’m interested in someone who is proficient in colonoscopy, proficient in upper endoscopy, maybe proficient in ERCP and is a good clinician. Good diagnostician. Okay. And so I’m talking to their residency directors, I’m talking to people who know them. Maybe I had the moonlight with me, but I’m trying to get some kind of sense of if they are a fit from a skillset perspective, that’s one thing. And so from a physician standpoint, you do have to have that, but for your employees, that skillset fit is much less important than the cultural fit. 

If I had to pick only one that I could get a fit for, I want the cultural fit because I can train anybody to do almost any job if they’re reasonably motivated. So you want some people that won’t be able to come in with a reasonable amount of skills, and then you coach them and you train them to hone those skills, but you can’t train lazy out of somebody. You can’t train apathy out of someone, not very easily. You can’t train dishonesty out of someone. So you need to hire for those cultural values that matter to your organization, and then you can coach the rest. And so the framework that I use for hiring people for a cultural fit, it’s actually very simple. It’s based on another book that I really love called “The Ideal Team Player” by a guy named Patrick Lencioni and he posits and I think he’s really right about this, that the ideal team player, the person that you want on your team has three characteristics. So number one, they’re humble. 

The humble team member is gonna be someone who is constantly looking to build up other people in the team. They’re constantly looking to give other people credit, to show excellence on the part of their team members. So that’s the person who’s humble. They’re not all out for themselves. They’re not out for glory. The second characteristic is that they are hungry, is the term that he uses. And what he means by hungry is that they’re never satisfied with just good enough. They’re always looking, how can I be 5% better? How could this be 8% safer? How can we do this in three minutes, fewer per action. So they’re always looking to make something better. And then the third characteristic is people smart. And so like a high emotional quotient or how you cue that kind of thing. So you want someone who’s good at recognizing social cues. They’re good at interpersonal dynamics. They’re good at communication. They’re good at integrating well into the general milieu of the team. So that’s the ideal team player. So those are the kinds of things that I’m looking for if I’m hiring somebody.

Cheng-Huai Ruan, M.D.

And it’s really hard to know, even just, when you first interviewed people, because people may seem very different with an interview, but do you have sort of like a timeline or a process where they’re like, you know what, we’re gonna do a trial period for a month or three weeks or three months, whichever, and there’s a review after that. How do you assess that?

Brent Lacey, M.D.

Okay. I love that you asked this question, this is critical. And almost every company I’ve ever worked with almost every physician team that I’ve ever coached, doesn’t do this very well. The normal business hiring process is an interview, two interviews, calling the references. It’s very simple. All right. And as you’re pointing out here, I think the question that you’re getting to is yeah. How can you really get a gauge of who someone is in two 30 minute interviews? And the obvious answer is you can’t, it’s impossible because anybody can fake being a nice person for 30 minutes. If they can’t, they’re sociopath and you’ll easily get them out, but almost anybody can fake being a nice person and say the right things in an interview, but it becomes a lot harder the more time you spend with people. And so what I generally advise people is that you need to have a longer hiring process and it needs to be more complex. 

And so just like you pointed out earlier, employee turnover is incredibly costly in terms of time. And it’s incredibly costly in terms of just money expense. So employee turnover, if you can minimize that on the backend and get your employee turnover rate from 18% a year down to 4% a year, and then you pull all that time into hiring the right people so that you’re not turning people over as often, you’ll have better culture, you’ll have fewer expenses, you’ll have less guilt, you’ll have more time saved. And it’s absolutely amazing. So what I usually recommend is increase the number of interviews and change up the format. And I’ve seen lots of people get very creative with this. So for example, I knew one company that they always included as part of their interviewing process, a trip somewhere, and maybe it was going out shopping, or just going out to the mall and just kind of hanging out, or maybe it’s going to a baseball game under the guise of like, hey, we just wanna wine and dine you. We wanna show you who we are, but really what you’re doing is you’re observing, you’re gauging who they are. So, because if you go out to a restaurant with somebody, a person who’s rude to a waiter, or who laughs when a waiter drops a dish or something like that. 

I mean, if that’s who they are, when they think they’re not being watched, it’s definitely who they’re gonna be when they come into your company. So I think that’s a really cool idea. Another one that I’ve seen that I think is really interesting is where a leader and their spouse will go out to dinner with the applicant and their spouse. And so, how does the interviewee treat their spouse? Do they hold the door open for them? Are they speaking about them with respect? Are they constantly talking over them and running over them in conversation? Is it apparent that they are a good dynamic, in a good dynamic relationship. And so the way that they interact with their spouse can be very telling. 

So those are ideas that you can do. And I love the idea of the probationary period. I’m a big fan of that. And so my general advice to folks is have a probationary period and I recommend 90 days. So work that into your contract where you can say either the employee or the employer can choose to terminate the employment contract without cause within 90 days. Because if you give people a long enough period, they will let down their guard and they will show you who they are. So they can maybe fake it for a week or two weeks or maybe a month. But it’s really hard to fake who you really are for 90 days. And so if they make it through that 90 day period, then they’re gonna be pretty solid. That is a great, great idea. I love the probationary period concept.

Cheng-Huai Ruan, M.D.

And for those people listening is like, why are we talking about this in the AI upgrade summit? And one of the reasons is because we can use technology all we want, but what to do with that information is so important. And a lot of that has to do with leadership and company culture. So I think that when we hire humans and humans are just naturally inconsistent when none of us are gonna be 100.0% right. The really good ones are maybe 95%, but there’s always gonna be 5% of something that’s dropped and what technology, if it’s built, right you can overcome a lot of those processes by being, 10 out of 10, a hundred percent on some of the smaller processes, but using, technology in AI and using all that data requires a very strong culture and a very strong team. And so, with that note, I think that we wanna talk about things that no one likes to talk about, which is, this is what I see when in a lot of clinical practices. 

And you just tell me, if that’s sort of the same thing that you’ve seen. You have a leader, whether that could be the physician or the office manager, whoever it is, you have a leader in the start and what you notice is a pattern. They start hiring people who are just like them. And so if they’re a one personality and then hire other people who are very similar personality, a lot of things gets missed. And so over time, if you have a lot of similar personalities within the company, in my experience, a lot of things can get dropped and I’ll give you an example. So, we use a DISC profile, DISC profile to profile all our employees or myself and within the DISC profile, I’m someone who’s relatively influential, but I’m very like big picture and not too detail oriented. And then I get a lot of like AD symptoms. When I looked at certain projects. And then so, I noticed that I tend to gravitate towards other people who are very similar because it kind of hypes me up, but then it just extenuates my weakness, I believe. But then I started looking at my other employees who have different aspects and people who are basically wanting to put me in check and that really helped me out. And so, but I think the problem is that a lot of this is subconscious thoughts that you subconsciously attracted to hiring people that are a lot like you. So tell me your experience and what that dynamic looks like.

Brent Lacey, M.D.

Yeah so you’ve hit on a really important point here when you’re in the hiring process. And this is part of what we were talking about a second ago, where you are deliberately making the hiring process more complex. It is critically important to get different people with different personalities, interacting with those candidates, because they’re gonna pick up stuff that you want. So you mentioned the DISC Profile and I’m a big fan of DISC. I think it’s a great tool. DISC is great. The Fascination Advantage is a great tool. StrengthsFinder is a good tool. Myers-Briggs is okay, but not really, as widely applicable, I think in the hiring process, but any one of those tools. And so I’m on the DISC Profile, I’m a high I and S. So I’m gonna be, I’m very people oriented. I’m very outgoing. I like everybody to be included.

I wanna get the group together and motivate that kind of thing. But you know, someone who is a really high C is gonna be maybe more detailed oriented. And so it’s very helpful to have different perspectives from different people, because I may feel like a guy that I’m hiring is kind of abrasive and kind of brash. And I’m not getting a good vibe from him, but then someone comes along behind me who interviews them and their ideal and they go, oh, this guy really gets it. He’s got a really good head for big picture. He’s got a really good concept for strategic thinking. And so then we start to integrate all these different perspectives and see, okay, we’re painting a picture. It’s like putting together a jigsaw puzzle or a patchwork quilt. You’re putting all these different items together and saying, okay, so paint me a picture of this person. 

What are some of their strengths? What are some of the areas that we need to, pay attention to as potential shortcomings or potential places where there’s gonna create conflict or friction among the other team members or with people that are leading or who are leading them. And so you start to recognize some of those things and pay attention to everybody’s perspective, and that becomes hugely helpful. So yes, getting people at different perspectives in, on a hiring process, in on the onboarding process and continually assessing the culture of the organization is absolutely critical.

Cheng-Huai Ruan, M.D.

Yeah and I think that also comes from like a very strong leadership. I think that one of the things that I learned a little bit later on in private practice is to establish a sort of set of core values within the company and adhere to those core values. And I think that most people have a generally a pretty good intention, but a lot of times the core values of a company of a medical practice can be lost on people. So what I think that, yes, there’s people who are inherently good, but leadership needs to have some sort of cohesive structure to always have those core values, know what direction we’re going. And the direction changes just like earlier on in 2021, COVID hit our direction changed. And when the directions changes that leader has to put everyone in the same direction, which is not an easy task. But that’s part of the leadership and culture. So how do we, as physicians, as physician leaders, how do we become that person that becomes the glue and becomes the cohesion of our company?

Brent Lacey, M.D.

So I think the things to remember is that as leaders, our goal is not to do everything. Our goal is to get the team where it needs to go. So if you go back to the bus analogy, it’s like we are the bus driver or the unseen hand guiding the bus or something. So I think it starts with the core values that you mentioned as leaders, it’s important to model and exhibit and celebrate and recognize those core values among your organization. So like where you mentioned last year with the COVID, you guys are making a big direction shift. That’s a very dangerous time for an organization because if you make a shift, or if you have to, call an audible and make a big change in the way your organization is going, it’s very important that you, as the leader, keep the organization tethered to those core values. 

So for example, in the middle of the pandemic, if you’re going from, a hundred percent in office to a hundred percent telehealth. And then an opportunity comes along for you guys to do some kind of investment in a telehealth startup company. So maybe that’s not the right thing for you guys to do. If your core values are, maximize time with patients, maximize education of our patient population, then getting into, tech startups, speculation, while it might be a good opportunity. If it doesn’t jive with your core values, it’s completely taking you off your game. It’s gonna completely rock the culture of your organization. So I think that’s the first thing is as a leader, it’s up to us to keep those core values front and center all the time and keep us tethered to that. So whatever decisions we make is it in line with those core values? So I think that’s number one. I think the second thing is providing some kind of structure and some kind of framework for allowing people to get their work done and get their job done in the best way possible. 

So one of my favorite books of all time, I think probably my top, the top one or top two is a book called “Ender’s Game”. It was a sci-fi book from the 80s and actually made a movie of it some years ago. But one of the things that I was really impressed with in that book is how they really talk a lot about leadership and culture and tactics is absolutely a really fascinating book. But one of the things that they talk about is how the army commanders that win, that do the best, aren’t the ones that are the best rifleman. They’re not the best tank drivers. They’re not the best spies necessarily. They’re the best at getting the best from talented people. So as a leader, you need to be constantly asking yourself not what can I do to today as far as like, what can I do mechanically within the hospital? It’s what can I do to support all the people that are doing their jobs? Because if you’re focused only on what your job is, then your company is gonna move at the speed of you. But if you’re instead focusing on making your job, the responsibility to have everybody else do their job more effectively, and you’re saying, how can I support my team? How can I get them more resources? How can I get them more time off so that they don’t face burnout? How can I make sure they get paid on time? 

And you’re multiplying the genius, multiplying the talents of everybody in your organization, and that’s for primary motivation, then your organization can come up with, instead of one brilliant idea at a time from you, it’s coming up with hundreds of brilliant ideas from everybody on your team. So I think those two things as a leader is keeping the company tethered to the core values and figuring out what are the best ways that I can support my people and give them the resources, the knowledge, the education, the training, and the money to be able to do their job more effectively.

Cheng-Huai Ruan, M.D.

I wanna cheer on that one. You put that so brilliantly and I a hundred percent agree. And the only reason I agree is I’ve been in the opposite realm and it wasn’t very fun.

Brent Lacey, M.D.

Well, and I think we probably all have, I mean, you think about all the organizations, all the rotations that you’ve ever had, the ones that were the most miserable were the ones where the leader was overbearing or was ineffective, or was just a really nasty personality. Or they were just ones that were really hard physically or mentally or emotionally. But the ones that always burned me out the most, they were always the hardest were always, always the ones where it was a rough cultural fit. So if our attending was just was mean a malignant, I still saw it as my responsibility to try to learn from the guy or from the gal. And if they taught me something, I was like, okay, well, at least I learned something, but don’t remember any of those rotations fondly by any stretch of the imagination. So yeah, we all have experienced that kind of thing. And this is a real problem among team members and employees, people do not leave companies because of money as a general rule. I mean, that is always an aspect of it, but by and large people don’t leave jobs because of money. They leave jobs because of their leaders. They leave jobs because of their bosses. That’s the number one thing in every poll that’s been done in businesses for decades is people leave their leadership.

Cheng-Huai Ruan, M.D.

And with leadership and getting the core values out there and having people understand what the core values are, but also remember when the core values are, and that’s a challenge on its own. And so, if I want to keep my employees. So let’s look at health care, for example. And earlier I talked about the turnover rate for employees is astronomically high within healthcare, especially since during COVID. And so if I want to prevent something like that, let’s say, there’s another pandemic or some sort of structure where, or just the collapse on a lot of systems in order for me to prevent that, I have to develop myself as a leader who understands the core values can build a company culture so that when that happens, people aren’t leaving. And thank God during the pandemic, all our staff actually stayed and everyone was very much into what our goal is trying to define, which it was just fabulous. My staff has been absolutely fabulous towards it. But if I wanna prevent that, if I’m a guy I’m a physician leader, I wanna prevent people from leaving. I wanna make sure our culture is good. And I currently have not such a great culture. What should I do?

Brent Lacey, M.D.

Yeah. I mean, it’s a great question. And there’s several things that I think you can do. The first thing I think you do is you got to take a hard look at what your culture actually is. Do a real cultural assessment. And I think it starts with just observing, just paying attention to things. So for example, as you’re in the clinic, as you’re sitting in the break room, as you’re walking around the offices, what are you hearing? Are people talking to each other? Are people smiling to people say hi to one another? Is there trash on the ground that people will keep walking past all the time? I mean they don’t take pride in their workplace? What is your actual culture right now? So doing an assessment of that, and after you do some observation, start talking to people, and what I think is one of the best things to do is start asking polarizing questions. What’s the hardest thing about working here? What’s the most frustrating thing about working here? What’s the worst aspect of this job?

Cheng-Huai Ruan, M.D.

It’s very counterintuitive.

Brent Lacey, M.D.

Do what?

Cheng-Huai Ruan, M.D.

It’s very counterintuitive. 

Brent Lacey, M.D.

Yeah, and so, and here’s the thing when you polarize it like that, everyone has an opinion suddenly. If you say, so is this a nice place to work? Do you like being here? People just wanna go along to get along. It’s like, oh yeah, that’s fine. it’s the standard answer. How are you doing? I’m all right. And really your life is falling apart, your kids are sick and your jobs hanging in the balance, and you’re worried about your mom or your dad or whatever. So if you ask questions that give people an easy out, they’ll take it. But if you ask them a polarizing question, say, what’s the biggest waste of time that you have to deal with on a daily basis? That one question, you will find so many people ready to answer that question. Like, let me tell you, doc, do you have a pen? ‘Cause I got six of them. And they’re all happy to tell you, what’s the biggest time vampire of their lives. So that’s a great place to start also. And so then as you’re trying to figure out, what the culture is, I think one of the next things you do is you start talking to your leaders. 

So we’re asking questions to real leaders, what are some areas where we’re falling short? What are some areas that people complain about? Who are people that are constantly having the most trouble? And then I think the third thing you have to do is start taking a really serious look at who’s working there. And this is one of the things that gets very tough. So if you’re new and you’re coming into an organization, you’re trying to figure out, okay, how can I impact this culture? How can I like make a difference here, almost guaranteed. If you’re coming into a culture and you’re new and you’re being hired to lead a team almost every time there’s at least one person and usually it’s three, it starts with a little triangle of people, but there’s almost always at least one or two or three people that are at the core of some negative toxic, gossip, mongering, hate spreading, disenfranchised, discontent, personalities. And very oftentimes what’s required is a publicized firing. So I don’t mean that you go and you’re celebrating, we’re firing Ted today. But you’d need to look at your organization and see who is it that isn’t cutting it. Isn’t pulling their weight. 

Who’s gossiping all the time, he’s constantly writing other people down. I guarantee you that if you are new to an organization and you’re finding that there’s a problem in the culture, there’s at least a few people that desperately need to go. And it’s up to you as the leader to root that out. And then to give them, hopefully give them an opportunity to rehab themselves. And if they don’t, you need to fire them and let them go. Because here’s the thing. if you wanna have a stable of thoroughbred race horses, and you let one donkey in there. And everybody sees that the donkey is given, a special privileges and special treatment because, oh, well, we’re not willing to enforce the rules. Who cares if they show up 30 minutes late, I’m never gonna chastise him about it. No, then you know, what’s gonna happen. All the thoroughbreds are gonna leave and go somewhere else and you’re left with the donkeys. And that’s just the reality. So if you don’t get rid of the bad people, the good ones will leave and the bad ones are all that you’re left with.

Cheng-Huai Ruan, M.D.

Yeah. I’m gonna summarize that into two statements that I got from Tony Robbins one time. The first one is you get what you tolerate.

Brent Lacey, M.D.

That is so true.

Cheng-Huai Ruan, M.D.

And the second one is you’re not necessarily who you hire, you are, who you don’t fire. So kind of ties towards the same thing.

Brent Lacey, M.D.

Well, and one of the questions that I’ve heard asked, and I think this is a great way to do this. So if you’re not sure if you wanna keep somebody ask yourself this question about any role in your organization. If I was going to hire someone for this role today, is the person who is currently in the role, the person that I would wanna hire? And if you say no, that person needs to be rehabbed, give them an opportunity to change and improve and give them some expectations and tell them they have to meet those expectations, or they need to be let go.

Cheng-Huai Ruan, M.D.

And you know, a lot of people listening to this, it may seem contradictory to what we talked about when we opened up is maintaining that company culture and make sure that everyone’s involved and have a good feeling. And you’re like, well, if I’m gonna be going around and seeing who I may need to get rid of, how’s that good? So, you know, one of the things I learned is that a good company culture is not a company that lets you bring your dog to work every day and just chill that’s not a company culture, right? So maybe a place where people wanna work because it’s relatively lax, but a good company culture is a strong leader with core values with direction. And so whenever you’re there looking at who does it belong in this position and anymore, maybe you’ve the company may have outgrown this person, think about it as I am making this decision to protect the family and protect the culture within there. 

And you’re right, because there are just one or two or three people that may be the toxicity within the actual culture. And if you, as a leader, don’t do anything about the toxicity that’s already recognized, then that disrupts the entire culture completely. And so I will love to think that a good company is all kumbaya, but it’s not. It’s about direction. And it’s about going in the direction where everyone wants to head in the same direction. And even if the employee has been great and does everything that they’re told, if their job involves more than doing things that they’re told, then the company might have outgrown that person. So thank you for saying that. I feel kind of validated because that’s sort of the direction that we’re taking in my company as well.

Brent Lacey, M.D.

Well, and I think as leaders, one of the things that we can and should do is to set those expectations in a very clear way. So if we’ve got someone that isn’t meeting expectations very often, I think it requires some deep introspection and say, okay, have I really enforced my expectations on this person? Are they just doing what they think they’re supposed to do because I haven’t said anything different. So it’s like when you’re dating someone and they say, and you can tell that something’s wrong and you say, well, what’s wrong, what’s the matter? He said, well, if you can’t figure it out, then I’m not gonna tell you. Well, what the heck do I do with that? So if you haven’t made those expectations very clear to your team members, then I think it’s important as leaders that we own that. So if I’m having a conversation with an employee that is really not making the grade, it might go something like this. It’s like, hey, listen Phil, this is gonna be a challenging conversation. 

And I’m gonna express some things that may sound kind of difficult to hear. And if I don’t express myself very effectively, I’m gonna ask you to pre forgive me for that. But I want you to succeed here. And I think that this is a great place to work, and I want you to remain a part of it. But the truth is that you’re not meeting the expectations that we have. And I feel like I have not done a good job as your leader in setting those expectations and making that very clear to you and then holding you to those standards. And that’s my fault. And I apologize that that’s on me. But here’s what we need to do. 

Starting today, we’re gonna make a change. Here’s the expectations that I have of you for your job. And you bring something written. It needs to be written down in black and white needs to be very clear and say, these are the key performance indicators. These are the key results areas, whatever you’re gonna use and say, these are the expectations that I have for you. You’re gonna do these things. You’re gonna show up on time. You’re not gonna show up late again. You’re gonna start dressing better. You’re gonna have better grooming standards. You’re gonna have increased productivity, better efficiency, whatever the things are, set those expectations say, this is what I expect of you. And what I need to see over the next 30 days. And you give them a finite period of time. 30 days is pretty good. So over the next 30 days, what I need to see is significant progress towards these goals. And by the end of 30 days, I expect you to be meeting each one of these key points. And we’re gonna meet together at the end of every single week. For the next four weeks, we’re gonna meet together every Friday and we’re gonna go over it. And I’m gonna tell you where I think you’re doing better and how you can improve and I’m gonna coach you. I’m gonna help you because I want you to succeed as your leader, but I’m gonna show you where you’re still falling short and you’re gonna ask me questions. And we’re gonna work together to try to get you where we need you to be. And then the next week you have the meeting and you say, okay, you’re doing great with these three. 

You’re not doing so great with these six. So let’s work on those. And then the next week, the same thing, the next week, the same thing. And one of a couple of things is gonna happen. One of three scenarios, one, they’re gonna go, oh my gosh, I had no idea. No one said anything to me in the last six months. I just assumed I was doing a great job. Thank you so much for making this clear. No problem. I’m gonna step this up. And within a week, two weeks, they’re gonna be on their game. They’re gonna be doing awesome. Scenario number two, is that by the end of the month, they’re great people. They’re wonderful person, or maybe they’re not, but for whatever reason, they’re just not cutting it. They’re not meeting your expectations and you say, listen, we’ve really worked this hard. we had a set plan to spend 30 days. 

You’re not meeting the expectations. Unfortunately, I don’t think this is gonna be the right company fit for you. We’re gonna let you go and we’re gonna write you a great recommendation ’cause we really like we want you to succeed, but this is not the place where you’re going to succeed. This is not the best fit for you. That’s the second scenario. The third scenario is interestingly, what’ll happen a lot of times. And I’ve heard you talk about this before. As a matter of fact, I think you talked about this on my podcast is that people will select out. So week one, you’re like, you’ve made 5% improvement on every area. And then week two, you’re like, you’ve made backward steps in three areas. And you keep having the same conversation. And by week three or something, they’re gonna go, okay, writing’s on the wall, I’m just gonna quit. And they just leave. And they’ll just select out. Either way at the end of that 30 days, you either have given them the opportunity to rehab themselves and they did, or they didn’t and you let them go or they just got better on their own.

Cheng-Huai Ruan, M.D.

Yeah, absolutely. And I’ve experienced that in myself as well. And so I think that a lot of people hearing this are gonna be like, oh my gosh, I see patients all day when the hell I’m gonna have time to set these structures up. So the next part of what we’re gonna talk about, which very, very few people do is something I like to call creating a Standard Operating Procedures, SOP. I think that whenever we as leaders are spending a lot of time with our employees and setting expectations, doing stuff, we expect a lot out of them, but a lot of them are just very heavily under-trained because there’s little tiny details and they not might not have been trained. And so we started using some platforms to create these standard operating procedures on the digital platform. But I think let’s really dive deep into this one because the last example we just used is something that I myself experienced with a lot of employees. But whenever we started creating structures and training and spend time doing that, a majority of that actually started going away. And then we were able to spend more time on culture and revenue generations and have a lot of fun with that. Because, it’s not really fun reprimanding somebody. But let’s talk about how important it is for us to document the procedures of what we are actually doing from an administrative point of view.

Brent Lacey, M.D.

Well, it’s important for a couple reasons. So it’s important for standardization because you don’t want people to be automatons. You don’t want mindless widgets, but at the same time, we do have to meet a certain standard of care. And so we do have a minimum set of expectations that people are gonna do certain things. So let’s take an example of a family practice. A family medicine practice, let’s say. And so they’re doling out vaccines. Well, there’s a standard way that we do vaccines. And so, but you may have four employees and they’re, they have six different ways of doing vaccines among the four of them or something. And so, some of them use alcohol, some of them use Chlorhexidine some of them use this gauge needle that gauge needle, and it’s all over the map. So, but if you have a standard operating procedure for, okay, here’s what you do. You need this set of equipment and you have a checklist, maybe let’s say, and then you do this first, this first, this next, this next, these are the things you document. These are the codes that you put in. 

This is the note that you need to send me to sign, whatever it is, and you do that. And then it gives you a standardization so that you can meet your minimum standard of care. And then you can give some people, some freedom to innovate beyond that, but certain things are just gonna be standardized. So that’s the first thing is that it gives you some standardization. The second thing is that it massively buys back time. And so the way that I kind of think about it, it’s a time investment. So, we talk about, for example, with saving for retirement, the earlier you start the less money you actually have to save because of the effect of the compounding of the interest. So you make a small investment up front and it reads huge dividends down the line. But yeah, you’re having to put in some startup capital. 

So now you take that same concept and apply it to what you just talked about with the standard operating procedures. If you take the opportunity to spend a little extra time training people, getting them up to speed, giving them the best skillset to be able to accomplish things, it will pay off an efficiency and time saved down the line. So if you have someone that normally takes 10 minutes to administer a flu vaccine and through training and repetition, and some coaching, you can get them down to five minutes. So let’s say I spend two hours, let’s say I spend two hours training someone how to do vaccines and I say five minutes per vaccine. Okay. So that’s 120 minutes. So that’s what? 12, 24 is 24 vaccines. And I’ve made up that time. And then I’ve made five minutes times every vaccine that they do from now until forever. So now they can do 20 vaccines. Let’s say in the time that they used to be able to do 10. And so now I’ve increased the number of vaccines that I can give. Now it starts to open up a lot of interesting ideas. So I’m just kind of riffing here, but now I’m saying, okay, all of a sudden I can do 20 vaccines in the same amount of time I could do 10. What if we set up a vaccine clinic somewhere? What if I sent this person to a school and said, hey, we’re gonna come to your school with a truckload of vaccines.

I got four people that can do 500 vaccines in a day. And you just send me all your kiddos and with permission slips, and here’s the form. And here you can upload a digitally for mom and dad and just send them through. And we’re just gonna get everybody vaccinated against the flu in a single day. Now that’s just one example of a way that your time investment can pay off. Or maybe it’s not about creating a new program. Maybe it’s just freeing up more time. So now in the same amount of time that they were doing the vaccine, now they can be, triaging another patient, or maybe they can be answering a phone call or checking an email or coming to talk to you about a problem with your supply chain, where you’re freeing up that time by investing a little time upfront so you reap the dividends later.

Cheng-Huai Ruan, M.D.

Yeah, that’s such a great point. And when you put it into that perspective, you’re turning something that’s seemingly very boring, which is SOPs and harnessing it. But what it allowed you to do is innovate on the backend. And so you create a structure and then you innovate and create and innovate. A lot of people with the DISC Profile I like myself and you, sometimes we tend to innovate and innovate, and then we have a little SOP here and that can really break everything down. But what you just said is such a fabulous point. And so, but that’s why all these little intricate details needs to be documented somewhere. And even if it’s absolutely obvious. So I was talking to another practice, who’s an OBGYN practice and there’s six of them. And each of the doctors do something a little different. And so when a medical assistants cross-cover, it is very difficult for them to do that. And I’m sure you experienced that in GI as well. 

So what my suggestion is, hey, why don’t you just create either do things the same, or just create training programs for the doctor. And then let’s say if there’s employee turnover with there recently was, then you can train that for this particular position. This is the MA for Dr. Smith. And this is the actual training program that is allowing the MA to work with Dr. Smith. And here’s a little test and then go ahead and do it. And so, and that actually worked out really well. And for us, a lot of times we work with virtual assistants, we work with a lot of virtual assistants and they could be across the country or across the world. We have virtual assistants in the Philippines and in Africa and one in New Jersey. And so in doing all this, we have to make sure that there is sort of a digital platform that they can do it, but it’s not just about the SOPs. It’s about adopting new programs. 

Let’s say that you’re watching this AI summit and you say, hey, this company looks really cool. I wanna adopt this, maybe this texting platform with the patients. Well, what you do is you take that and then you say, well, how do we incorporate this into the practice? You don’t just drop it on your staff and just start using it. You know, it’s not that obvious. And so you have to create a procedures around it. And how do you incorporate with this particular program? And so I think that a lot of times when we are searching for technology to overcome pain points, we tend to skip over the operating procedure part, because this is not a sexy thing to do at the very beginning until you tasted the bitterness. And you’re like, okay, maybe we want to set up a structure around it. So that’s a fabulous point. But I think leaders right?

Brent Lacey, M.D.

One of the things that you can do is a way to multiply your time even more is empower your team members to do the SOPs. So in your example, you just gave, if you have an SOP or a way of doing things or a new technology from another company that you wanna bring home, you can give that to one of your go getter team members and say, hey, listen, we’ve got this thing here. It worked really well. This other company, I saw it. I think it’s really cool. I think it could work for us. Can you put together an SOP for me? Or can you take a look, is this adaptable to our culture and our business model and our organization? And if you think so, I want you to take a crack at an SOP of how would you teach everybody that’s at your level how to do this. And so you’re not even the one spending the time. 

That’s a five minute, that’s a 10, 15 minute conversation with someone saying, these are the goals that I want this to achieve. I want you to figure out how to make that work. And then they bring you a draft of the SOP. You work with them, maybe that’s another 20 minutes. And then you send them back. And then a week later, they come back with a new draft and then, you send it back. And then maybe you’ve spent an hour on that, okay. Over the course of say a month, all right. But you’re doing two things. Number one is you’re offloading things from your place. So you can focus on things that only you can do. And the second is you’re empowering your team members to do something valuable. And the more that you get your team members involved in the process, the more that they are likely to have buy-in, and the more they’re likely to actually come up with something that works, because here’s the other thing to think about. 

So like in the setting of say a gastroenterology practice, what I think I’m gonna want out of an SOP may not end up being the best thing. So I’ve got, GI texts that have worked for us for 10, 15 years. And they’ve tech for thousands of cases with dozens of doctors. And so what I do in my idiosyncrasies in the procedure room may be very different from what somebody else does. And so what, the way that I would write an SOP may not be something that can be standardized across the entire organization. And so getting someone who’s really boots on the ground, who really has their fingers in the inner workings of that particular process can be hugely valuable. So, ’cause you’re getting better expertise and you’re getting more, up-to-date, you’re giving them opportunities to grow. You’re getting opportunities for them to have more buy-in, it’s just great all the way around, but that’s a great example of what we talked earlier about, which is, instead of me trying to do it all is me empowering my team to do the best job that they can. And so then I’m multiplying the genius of everybody in the organization instead of just moving at the speed of me.

Cheng-Huai Ruan, M.D.

Yeah and not only that, because if you standardize the approach and standardize the training, you’re also able to gauge your employees. It’s like, hey, you did this training two and a half months ago yet you’re still, missing the mark here. What I do is that we as employees retrain as part of the corrections program. And so that and most people do just fine after the second time. And so we were able to have quality control over the procedures over the employees, but it allows everyone else as sort of a sigh of relief, right now what a lot of clinics are experiencing is that there’s rapid turnover. Now you have the most senior MAs train all these different people. And then right when they’re trained, they’re like, no, I don’t want this job when they go somewhere else. 

And that turnover is hideous to the bottom line because the fixed cost is so astronomically great. And so with the standard operating procedures, these SOPs we’re able to get people trained, very uniform and come in and then your senior staff may act as leaders rather than direct trainers. And that allows them to be part of the process, which I think hits three very human emotions. One is significance that they feel significant. You and your staff to feel significant. Two is a sense of contribution, to contributing to the company by being those leaders. And the third thing is connection. Once if people are going through a standardized training, it allows more time for that connection and more time to have those conversations. And I think by documenting these things and they’re not fun, for me that we’re able to achieve that. But like you said, sometimes we feel like we have to do everything on our own, but we do have our employees create things of their best practices and they come up with the most innovative things I’ve ever seen. It just amazes me how we have so many great ideas. And when we change things up, everyone’s on board. And so, I think that allows me to be a good leader. And that allows me to really spend time on the conversation, employees making sure that their lives are okay. And that significantly reduces turnover. And so–

Brent Lacey, M.D.

Tying that back to one of the points we made earlier, when we were talking about the hiring process about hiring for a skillset versus hiring for a cultural fit. If you’ve got those SOPs in place, and people have a basic set of skills, you put them through that training. You don’t have to worry nearly as much about hiring for the skillset because you can hire for the cultural fit and then train the skillset.

Cheng-Huai Ruan, M.D.

Yeah, absolutely. And so what are three things you wish you knew about leadership when you first started private practice?

Brent Lacey, M.D.

So the first thing is that difficult conversations are painful but necessary. And so I’m very much a people person, very much a people pleaser. And so having difficult conversations where I have to address somebody down or tell them that they’re not meeting the mark or even fire somebody, that kind of thing, those are incredibly painful. I mean, it’s like a piece of my soul is being ripped out whenever I have those conversations is viscerally painful to me, but just so necessary. And so I’ve had conversations with people where we had to let somebody go and then a day or two later, one of my employees would come to me and say, thank you so much for being willing to take a stand and let that person go. We are all just so relieved that they’re gone. And immediately the productivity of the entire company goes up. It’s like, well damn, sorry I waited so long to do that. So, that’s the first thing I would say. 

The second thing I would say is that never underestimate the ability of an empowered team. And so what I mean by that is that if you, as the leader are giving your team direction and encouragement, and then just turning them loose to do whatever it is you want them to do. Just sit back and prepare to be amazed. You get the right people, you get them doing the right job and you give them some direction and just watch them blow your mind. It’s amazing. Like you were saying a second ago, I mean it’s just phenomenal seeing the stuff that people can come up with. It’s great. And the third thing I would say is, do not, do not, do not underestimate the value and importance of a healthy team culture. There is just no substitute for it. So I read in a leadership book one time, this Maxim, culture eats strategy for breakfast. And that’s 100% right. So if you’ve got great vision, great strategic thinking, great planning, great supply chains, a great five-year plan and your culture is lousy. 

None of it’s gonna matter. So it’s like going into battle with an army that has just horrible morale and everyone hates each other. It doesn’t matter how good your strategy is. You’re gonna get slaughtered. So don’t underestimate the value and importance and the critical role that a leader plays in shaping that company culture and take charge of that. Take ownership over that, make that a priority for you. Even if you don’t feel like you don’t have time, trust me, you do not have time to not pay attention to that and to not do it.

Cheng-Huai Ruan, M.D.

Wonderful, everyone if you haven’t already clicked the link for the Scope of Practice Podcast, I’ve listened to a lot of them. And a lot of this actually is covered in there with the different physicians in very different scenarios. And it’s something I truly enjoy. So Brent Lacey, how do people find you?

Brent Lacey, M.D.

So the website is thescopeofpractice.com and you can get access to the podcast through there. And so people need to go listen to your episode, ’cause that was absolutely phenomenal, and you can get access to the blog archives. You can connect with me. But I wanna give the listeners something to take away ’cause I think it’s helpful to have some tools as a leader, something practical that you can actually start to, deploy in your own practice. And so I created a guide just for the Summit Watchers here, it’s called, five critical tools that every physician leader needs. And so it’ll help you find ways to celebrate your team members. It’ll give you a 10 day challenge to make your clinic better. It’ll help you set up a mission statement for our organization and a few other things. So people can download that, that’s for free at thescopeofpractice.com/physicianleadertools. So they can just download that guide for free at thescopeofpractice.com/physicianleadertools.

Cheng-Huai Ruan, M.D.

And the link is in the description of this episode. So thank you so much for coming on today and taken out of your valuable time. And this has been an absolute enlightening conversation and somewhat validating as well. And I think it’s really important for all us all to be fantastic leaders for our patients and for employees and our staff and our families as well. Thank you.

Brent Lacey, M.D.

Thank you Dr. Ruan, appreciate it. Thanks for having me on.

Cheng-Huai Ruan, M.D.

Thank you.