Joy in Leaders = Joy in Work

Focusing on joy, especially in work, is gaining momentum. It has my attention! It is clear to me that the mindset and habits are exactly what great leaders have and do and what developing leaders should concentrate on.

It is very tempting for any leader, especially those in healthcare, to focus on what’s wrong, what needs to be fixed. It’s time to view the situation through a different lens…we need to focus on the meaning and purpose of our work. This is a distinct advantage for those of us in healthcare, our mission is making peoples lives better. Joy is not in things, it is in US. IHI describes pride in workmanship as a fundamental right; having the connection to meaning and purpose promotes such pride and is the basis of joy.

Take the Joy Quiz.

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Lessons from Global Health Development: Harnessing Methods of Change

This is Part 3A of this three-part series.

Read part 2.

This Part 3A briefly reviews four change methods and Part 3B will compare them

“I have no idea how to change anyone. But I carry around a long list of people in case I ever figure out how.” - Anonymous

Eliminate four billion dollars of waste from a large healthcare system next year. Increase the CMS TPS (Total Performance Score) for a hospital from the national average of 38.1 to 60 in two years. Reduce maternal, child and infant mortality in Nigeria by 50% in three years. These are large-scale improvement goals – at healthcare system, hospital and population health levels, respectively.

Improvement at the community, organization and individual levels are all connected: improvement requires change and all change is personal. An organization is a group of people with a common purpose; and a community is a group of people with the potential for acting together (Taylor). While communities and organizations are made up of individuals, how they evolve and change is not merely an additive process of how each individual changes. Societies and organizations are complex adapting systems and their advancement matures through their disciplined movement.

Read Full Article.

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Lessons from Global Health Development: Sustainable Change Contrarian

Part 1 of a three-part series

“We cannot solve our problems with the same level of thinking that created them.” ― Albert Einstein

In the U.S., some refer to healthcare system change as an oxymoron. It is complicated. It is hard. And while progress has been made, we have a long way to go.

But if such change in healthcare is challenging in the richest nation, then imagine it in low resource countries. In many sub-Saharan African countries, healthcare must compete with investment in other more impactful determinants of health such as education, food security, and sanitation that, if present, are weakly established. Layer in different governments, languages/dialects, and cultures; include frontier rural locations, tribal influences and religious differences and the challenge to improve health and healthcare in countries such as Tanzania, Madagascar, and Nigeria can feel truly overwhelming.

Historically, the traditional approach to both change in U.S. healthcare and global development has been to identify needs and direct resources, typically money, at the perceived needs. This pattern has resulted in little success and in many cases, regression, harm and/or increased costs. In global development, despite over a trillion dollars channeled to low resource countries in the past two decades, little progress – and often regress – has resulted (Taylor, Empowerment On An Unstable Planet). In U.S. healthcare, it has created and perpetuated a medical industrial system that is three times as expensive as other countries for almost median outcomes. The lesson? Funds are zero sum limited; human energy is not. And the only real empowerment is self-empowerment.

Read Full Article.

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Good Leaders Drive Results!

Leaders are expected to be creative problem solvers, challenge the status quo and visualize problems before they occur. Your success as a leader is largely dependent upon how quickly you seek improvement in broken processes, develop new procedures and maximize efficiency and effectiveness.

Below are three tips to help you stay in front of the curve when managing your people and organization through change and drive results: Read Full Article.

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Sustainable Population Health:

Part B – Catcher or Pitcher?

Part B of this article addresses how growth plans of healthcare systems distinguish population health management from community and public health.

Part A of this article clarified the terminology and implications of Community, Public and Population Health. So what does all this this mean for healthcare system leaders’ growth plans?

Healthcare providers have historically played catcher, “receiving” patients who sought care. Access meant being available when and where patients sought them. The transition from volume-based care to population health management requires a role change of providers from catcher/receiver to pitcher/initiator. The transfer of utilization and intensity (and possibly actuarial) risk to providers requires providers to be economically accountable for care and the health of a population. The good news is that this is a better alignment with the societal view of healthcare as a service (in economics, a ‘good’ with a cost) that is necessary but not a value-add. The bad news for providers is that this is contrary to traditional culture and payment incentives. This change is not a transition, but a transformation that involves many transitions.

Is Less Healthcare Better?

From a community and public health perspective, success involves preventing disease and reducing the demand for healthcare services. Success for providers often means growth in healthcare services. Traditional revenue growth for providers involved price and quantity (P & Q). Providers feel conflicted: more P and Q meant economic success, but now, with increasing “value-based” care (more-risk, if not full risk), less P and Q means success.

Studies have called out pricing as the primary reason why costs in the U.S. are significantly higher than in other developed countries (Uwe Reinhart, ‘It’s the Prices Stupid’). Increasingly transparent societal forces are serving to limit growth in P. And the ascendance of population health management is serving to put downward pressure on Q – the quantity of health services provided. Read Full Article.

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Eating Live Frogs and Other Strategies to Organize Your Work

Mark Twain said, “Eat a live frog first thing in the morning and nothing worse will happen to you the rest of the day.” When I first read this quote, I thought it was just a bit of silliness and good fun, but I read once that it meant that you should tackle your most dreaded task first. This is good advice for often dreaded tasks are not as difficult as we feared. We just need to get started.

My long-range calendar is kept in Outlook, but I do not use Outlook to keep track of what I need to do today. I have often found myself ranging over the hospital so I would not have immediate access to my desktop computer. I also want to be able to talk on my phone and look at my schedule at the same time. So, to prepare for tomorrow, I pull out an unlined 3 x 5 index file card. Orienting it in a portrait layout, I write the day of the week and the date at the top. Below this I write in my known schedule for the day. If meetings are back to back, I write them with no space in between. If I have time between meetings, I leave space to write in commitments that will be made that day.

If you have a job with clear and regular boundaries between work and personal time, it may be practical to keep two separate calendars. But those of us in leadership, especially hospital leadership, find the boundary between work and personal time to be very fluid. We may have to come in early one day to meet with the surgeons and the next day stay a couple of hours into the evening for hospital committee meetings. Under these circumstances, it is critical that there only be one calendar on which is kept all work and personal commitments. One of Steve Jobs’ daughters understood this principle well. When her father would commit to spend time with her, she would call his secretary and have her add the event to his calendar.

If someone helps you with your schedule, it may be necessary to give them access to your Outlook calendar so that they can schedule meetings for you. If you feel you need privacy, it is possible to add things to your Outlook calendar such that others can see that the time is blocked but cannot see how you labeled the event.

On the backside of the 3 x 5 index file card, I write my “to do” list. These are things that I want to get done in my open time between meetings. As things are completed, I cross them off. Anything uncompleted by the end of the day, can be added to the next day’s “to do” list. For me there is always something to carry over on my “to do” list to the next day for I am a very ambitious “to do” list writer.

So how do we prioritize our “to do” list? We can begin by looking at our list in terms of a Johari window. Tasks can be divided into urgent & important, not urgent & important, urgent & not important and not urgent & not important. We must be careful about how we characterize our tasks. We may think that something is not important, but we can make a serious mistake if we decide that a task in unimportant while our boss thinks it is extremely important. We can lighten our load and focus our energies by removing things that are truly not important from our “to do” list. In the short term we must tackle urgent and important tasks, but in the long run we want to complete our tasks that are important while they are still not urgent.

There is merit in quickly knocking out easy tasks that are important, but we must not allow our sense of accomplishment to excuse us from tackling difficult tasks that we need to get done.

No is a word that I do not like to say to my superiors. I was hired to make things happen and to get things done. I was hired to be a solution to problems. When given a problem, I want to serve, I want to help. This can result in overloading my schedule. After starting a job as a physician leader, I was invited to sit on several committees. Early on I was given advice by one of my bosses that I should limit the number of committees that I sat on. So, I asked him to give me a number of how many committees he thought I should be on. As I accepted these committee assignments, I let them know that I had a limited number of committees that I could be on and that I might have to step down from their committee if the hospital needed me somewhere else. I had the advantage that I oversaw 22 physicians and four nurse practitioners who each needed to sit on at least two hospital committees. With so many providers needing committees, I struggled to find places for them all. When I needed to step down from one committee to take on a more important assignment, I was always able to replace myself with one of these providers.

Stephen Covey listed “sharpen your saw” as one the seven habits of highly successful people. A carpenter who only saws and never takes the time to sharpen his blade will be very unproductive sawing with a dull blade. We must take time to plan, prioritize and organize our work. This gives our work focus and power. We feel more effective, because we are more effective, and that sense of accomplishment brings joy and meaning to our work.

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In Praise of Corporate Tension

“Corporate will be here next week to help…”

“Corporate is sending out a team in person to review the project.”

“Corporate is coming out for a visit.”

These words can immobilize the most courageous of hearts. Many at the clinical sites believe corporate exists to disrupt and provide self-enhancement for the corporate individual making the demand. The incoming request often appears as a consistent disruptor to the local individual who is focused on the hospital, clinic or community issues. As a non-corporate individual, you are at the site addressing immediate and multiple priorities. The demands can range from concerns for improving patient care, addressing colleague concerns or responding to the corporate enhanced financial issues to name just a few of the more common daily agenda items. In fact, you may even be reacting to a situation affecting the greater importance (?) of your immediate supervisory interacting environment (i.e. keeping your local boss happy). Whatever the corporate demand at the time, it can seem to distract from the work necessary to be successful at the site. Furthermore, from the limited view in field, the request can sometimes make no sense as to its timing or priority except “Home Office needs it now.”

The tension between the entities in the field and the corporate power is real. The euphemism of “Corporate,” with all of its priority setting, sweeping powers, and down-flowing time demands can cause untold tension and disruption at the sites. However, corporate has its own demands and in the final measure is often made up of people just attempting to survive and succeed. Good leaders are conscientious individuals balancing competing demands, shifting priorities, and seemingly continuously adjusting metrics driven by someone else’s “higher-up” tinkering. Both sections of the organization contain people searching for a positive impact. Same organization. Different pressures. Competing language. How does that language sound as a result of differing views? Let’s take a look and listen in: Read Full Article.

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The Cultural Leadership effect -- it starts with you

The leadership team is responsible for strategy. It is a major portion of our many meeting agendas. We have all seen or created the list of items and our strategy focus may vary from how to enhance our service line growth, to retaining and recruiting more nurses, or focusing on the improvement necessary to boost the patient scores and much, much more: however, as leaders we all know what must always be forefront on our strategic agenda, taking care of our employees.

How many times have you seen where the Administrative Team gets together, decides they are all going to Round together, and their assistants (with repetitive internal mirth) agonizingly make the schedule, coordinating whereby everyone can Round together. It lasts for a few months, weeks or even never gets completely off the ground despite the many studies showing its benefit. It is not out of leadership neglect, but the daily re-prioritization battle that necessitates our lives. Nevertheless, the focus on your employees must always take precedence.

The questions must then be asked: How is this precedence displayed? How do you show you care about your employees? Read Full Article.

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Decision Making Traps: Decider Beware

Leadership Transformation Series

This is Part 4A in this Four-part Leadership Transformation Series (LTS); 4B will follow.

Transformation in healthcare is personal: it requires the transformation of health system leaders. The LTS begins to speak to key differences in some of the fundamentals of transformational vs traditional leadership in healthcare.

This article focuses on how we make decisions: 4A Reviews decision-making errors.

4B Addresses how to mitigate decision-making errors

Leaders – and their organizations - succeed or fail based on their decisions. Yet the evidence is clear that our decision making is perilously fraught with biases and irrational behaviors of which we are not even aware. These biases are so ingrained in our psyche that, like water to fish, we cannot imagine that they are even there, much less clouding our view – regardless of how “well-intended and objective” we believe we are. In short, bad decision-making is largely hard-wired.’ Just as many medical errors are associated with unexplained variation in medical decision-making (How Doctors Think), so too are many leadership errors are associated with unexplained variation in management decision making.

Traditional change is oriented in the past; it involves more, faster, better, but not different (Daniel Prosser). Transformation is future-oriented; it requires the creation of something from nothing, i.e., letting go and giving up something in the past to create something new. This means that, to do transformation well, it is even more important that our hidden decision biases be flushed out and made explicit. Leaders on a transformation journey are at higher risk for decision making traps and consequences than in traditional change. Said differently, leadership decision making in transformation is less forgiving.

A brief review of categories and types of decision and judgement errors include the following: (Read Full Article)

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Five things every CEO needs to do

It is a truth. As CEOs, we are pulled in many directions. The incessant priorities, though seemingly always valuable, will consistently distract us from our most meaningful impact. How does a CEO maintain their focus and discipline on what is important when everything is significant? They must focus on what is central to the organization’s success. The following five imperatives will aid in this journey:

1) Visible Listener:

The CEO must be a good listener who spends time greeting, listening and positively interacting with the individuals on the floors and in the clinics. Ninety-Five percent of your time should be spent listening. Hearing from the people doing the work who can keep you informed of the issues they are solving through the work-around of their own ingenuity. You have an opportunity to develop relationships, listen for trends, solve problems and gain credibility as a CEO who cares about the people enough to make them a priority in your busy day. Read Full Article.https://www.rodneyreider.com/blog/2019/2/7/five-things-every-ceo-needs-to-do

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The Operating Model: Closing the Strategy-Execution Gap

Leadership Transformation Series

The Operating Model: Closing the Strategy-Execution Gap

This is Part 3 of a Four-Part Leadership Transformation Series (LTS).

Read Part 1 and Part 2.

Transformation in healthcare is personal: it requires the transformation of health system leaders. This LTS begins to speak to key differences in some of the fundamentals of transformational vs traditional leadership in healthcare.

This article focuses on how leaders operate.

You have a strategy. How do you rate your organization’s execution of that strategy on a 1-10 scale? For most, it is not high – or as high as they would like. Closing the strategy-implementation (aka, the knowing-doing or what-how) gap is the leadership Achilles heel of any business, but especially for hospitals, a business recognized by Drucker as the most complex organization to lead. Given that his observation pre-dated some of today’s larger and more evolved and blended academic-community healthcare systems, the complexity he referred to then has only increased. Across industries, the results of studies consistently identify unsuccessful execution for the vast majority of strategies; and the results of CEO surveys cite execution as the biggest current challenge, but reasons for such failure and concern vary widely. A sampling of HBR articles on the topic cite too much of an internal focus, poor CEO preparation in both strategy AND execution, “a people problem.” (Read Full Article)

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The Power of Simplicity

My father taught us, “If you want to be happy, simplify, simplify, simplify.” He loved the quote from the movie, Amadeus, in which the Austrian emperor told Mozart that his music had “too many notes.” My father did not agree with the criticism of Mozart’s music, but felt the quote was great for describing anything from cluttered architecture and art to overly complex solutions to problems. His house that he built from steel is pictured with this article. It is an expression of his design and artistic philosophy: clean, smooth, uncluttered, simple lines.

Albert Einstein said, “The definition of genius is taking the complex and making it simple.” Steve Jobs surely met this definition as he brought us the power and complexity of computing through as simple a user interface as possible. He took the complex and made it simple.

We often find that we cannot complete all of the tasks that are already on our “to do” lists let alone other tasks and goals we should be adding. We can choose what is most important to us and drop some good things from our list that are standing in the way of our accomplishing better. Advice I received from the book, Scrum: The Art of Doing Twice the Work in Half the Time by Jeff Sutherland and JJ Sutherland, helped a lot. Give yourself a short deadline. I needed to write an application to the Texas Medical Board to start a hospitalist fellowship. It seemed to me like this should take several weeks to complete which I did not have so I kept pushing it down on my to do list. I gave one of my hospitalists and me two hours to complete the application. We were done, and the application was accepted. My inner OCD wanted to overly complicate the task. I needed to simplify. Read Full Article.

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Rural Health's Specialty Lies in the Special Care

It was my first time back to a rural hospital. Though I had practically grown-up in rural health – both with frequent visits as a volunteer and as a support services employee – I had not been within the walls of a rural hospital in many years. And never had I been in one as a healthcare executive.

I arrived early, intending to look around and meet a few staff to better prepare me for a meeting with the Critical Access Hospital’s Board of Directors.

One of my first interactions was with a nurse coming out of a patient room. She was clearly emotional. Practically crying. I had seen the impact of caring for patients over the years. But this was not that. No, it was not simply a nurse and patient, but something much more. Even with my many years of experience, I didn’t yet know what I didn’t know – or regrettably, perhaps had forgotten. (Read Full Article)

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How to ‘Stop the Insanity’ and Pave the Way to Real Achievements

I am sure you have heard the old adage “the definition of insanity is to keep doing the same thing over and over again expecting a different result.” I would like to expand to that definition “and doing something without appropriate planning and expecting a better outcome.” Have you ever witnessed an unexpected result or outcome followed by a flurry of activity which is expected to positively impact the outcome? The danger of this reactionary activity is the false sense that the problem is being solved. Reactionary activity may address the fringe of the problem, but the root cause remains festering and aggravating the organization. To help with the risk of confusing activity with root cause problem solving, I suggest the Four Steps to Achievement, or what I like to call P8. Read the Full Article

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Systemizing Healthcare: The Integrator Role

This is Part 2 of a Four-part Leadership Transformation Series (LTS). (Read Part 1 Here)

Transformation in healthcare is personal: it requires the transformation of health system leaders. This LTS begins to speak to key differences in some of the fundamentals of transformational vs traditional leadership in healthcare.

This article focuses on the changing role delineation of leaders.

The leadership need for ‘the Integrator’ is re-shaping traditional CEO and COO roles.

A few decades ago, the role of ‘the Integrator’ in healthcare leadership did not exist – at least not in the form needed today. Unlike roles with new names – CTO, CMIO, CPHMO, etc. - the same titles of CEO or COO may be used for a healthcare system, yet the shapes of these roles bear little resemblance to those with the same titles used in a hospital or other ‘vertical.’

While a hospital administrator/CEO is expected to stay close to the pulse of acute care operations, the system CEO is expected to transcend operations to assure an aerial view/perspective, i.e., to become more visionary and system-focused. The transition from hospital to system requires a view that is less entrenched with how we have run hospitals and more focused on the population served. Despite use of the same title for both roles, it is the difference between being ‘tied down’ and ‘freed up.’ (REAd Full Article)

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When is achieving all your goals not good enough?

We’ve closed the books on another year, and it’s time to review your performance. Maybe you’ve completed all your goals -- congratulations you’ve failed. Failed? How could that be, I’ve completed all my goals? And therein lies the problem, you didn’t set your goals (or the bar) high enough for your own performance. Goals by definition are aspirations and should be set high enough to stretch the organization and yourself in new directions. If you are constantly beating your goals, you’re not stretching enough.

But why don’t we set our goals high enough? Well, it’s complicated. It has a lot to do with you, and with equal parts of your companies’ culture and goal setting process.

Take this simple test: Read Full Article

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Patient Care Experience Beyond the Medicine

INTEGRATING SUPPORT SERVICES AND FAMILIES FOR PSYCHOSOCIAL CARE.

He is that family member we all know, regrettably often looked upon as bothersome, annoying or cantankerous. Throughout my career in home health, skilled nursing and acute care, these family members are at every level – anywhere that involves caring for vulnerable patients.

One doesn’t even have to be in patient care – simply working in healthcare means each of us will likely deal with these troublesome family members at one time or another.

I was still a teenager when I first encountered “the husband” as we came to know him. Little did I know that those few days with him would have an impact upon my entire future, and that of my very role as a healthcare leader.

Interacting with patients’ families while working both in dietary as a dishwasher/server and facilities as housekeeping/maintenance taught me the importance of both support services and family members within the patient care experience – beyond the medicine. Read Full Article

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Focus on Culture for Patient and Family Care: Beyond the Medicine

As healthcare (including acute care, nursing homes, home health and all downstream providers) moves towards a greater focus on patient/family satisfaction, the model of healthcare must also evolve, for both the government and patients/families will be closely reviewing these in determining healthcare provider(s) of choice. A satisfied patient is a more compliant patient, making for a more engaged patient. Providers at every level must now move beyond the patient centered approach, into an understanding of the patient/family perspective and be willing and able to convert input to action and measurable goals, benefiting staff, patients and families. Read Full Article

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Healthcare Integration: Ship-to-Shore Work and the Ultimate Weapon

Veterans Day reminds me of my father. In WWII, he landed on Omaha Beach on D-Day.

As Steven Ambrose details in his book “D-Day,” the Allies planned the Normandy invasion for three years, but as soon as our troops hit the beaches, the plans went out the window. To the ‘man on the ground,’ NOTHING was as planned. And on the beaches, formal leaders were dead or not available. Survival and progress to save the free world depended on rapid learning and action, i.e., adaptive leadership. Our troops felt empowered to act, German forces felt compelled to wait for Hitler’s direction. The rest of this leadership story, as they say, is history.

Despite asserting to my Dad, in my youth, the growing impact of technology, e.g., pilotless planes, long-range capabilities, etc., he remained convicted of the mantra “the ultimate weapon is the man on the ground.”* My Dad and his colleagues, some of whom made it past D-Day, are heroes. I have since learned that there were others “on the ground” back in the U.S. who heroically enabled these heroes. During the planning for the largest invasion in modern history, a significant challenge was figuring out how to get our troops from ‘ship-to-shore.’ The U.S. federal government knew how make large ships to get our troops across the English Channel, but they could not get our troops to the shore. Enter Andrew Jackson Higgins, who was described by Dwight D. Eisenhower in 1964 as “the man who won the war for us.” (Read Full Article)

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Congrats you got the job! Read before you sign.

A physician who I greatly admire and respect once took a job as a hospitalist in a small town. She was told that she would have a guaranteed salary. But she did not read the fine print in her employment contract. The guarantee was actually an advance against future production, or collections. She was required to meet a certain level of collections to support her salary. If she did not meet that level of collections, she had to pay back the deficit. There was a hospitalist outside of and competing with her group. One of the emergency department physicians really liked this hospitalist. If he determined that the patient had good insurance, he called the outside hospitalist to do the admission. If he determined that the patient did not have good insurance, he called my friend’s hospitalist group. They were providing a tremendous amount of care to the patients in the hospital. They were just not getting paid. The longer she worked there, the deeper in debt she was getting. One of her partners did the math and simply left. My friend stayed out of a sense of integrity and fairness to give them time to find her replacement. She was not repaid in kind. And who was going to come and take over for such a terrible deal? She ended up in court and had to pay everything that the hospital was demanding of her. The judge said that it was a terrible contract, but a legally binding one and that she was a big girl and should have read the contract. Her partner who left early made the right decision in that she paid much less to the hospital.

When I was in medical school, we had a medical legal course which consisted of about 10 hours of lectures. One of the things that we were told was to read very carefully anything that we put our signature to. We were particularly cautioned to read employment contracts. I have followed this advice, and it has served me very well. I know of some stories where physicians were badly injured for not having read their employment contracts.

The first question is, “Will I be paid as an employee or as a contractor?” If an employee, then the employer pays half of the Social Security and Medicare taxes. If a contractor, then you pay all of the Social Security and Medicare taxes. If paid a salary, you will get a set amount of money, usually every two weeks or every month. Most people who are paid a salary are expected to work significantly more than 40 hours per week, because there is no additional cost to the employer for extra hours that you work. Many job offers will sound like salaried positions, but close examination of the contract will reveal that all or a significant portion of the payment offered is contingent upon one or more performance metrics. These metrics may include collections, relative value units (RVU’s), quality & efficiency. These may be based on individual performance, group performance or some combination of both. Collections is how much was actually paid for the care you delivered. Usually, a percentage of your collections is paid to the group or hospital for overhead. RVU payment is based not on collections, but on billing. This system is often used by organizations that serve the underserved as it encourages physicians to deliver care regardless of an individual’s ability to pay. Increasingly large portions of physicians’ compensation packages are only paid if the individual and/or group meet certain quality and efficiency metrics. Whether you are actually in control of a metric, the manner in which the metric is tracked & calculated and the thresholds to qualify for the metric all can have significant impact on your actual compensation. Benefit packages can also have significant impact.

In such a short article, I cannot tell you everything to look for. I would advise you to look closely at the exit clauses. When you go to work for a new employer, you have great hopes and even expectations that things are going to go very well. But they may not. I heard of a physician who, within two months of joining a new group, learned that his partners were engaged in and engaging him in activity of questionable legality. The exit clauses in his contract were onerous, and it was very costly for him to leave so early. Issues that may hit you with early separation can include repayment of sign-on bonuses, repayment of moving stipends and noncompete clauses. I was once invited to sign a contract that said I could not work for two years in any hospital anywhere in the United States owned by any company or organization that had a contract with this large physician staffing company (which had hospital contracts in many states).

So how do you go about reading an employment contract? Of course, you are not going to receive a copy of the contract until after you have been given an offer of employment. The contract is usually sent as a PDF. You can either print it out and use a highlighter and an ink pen or, if you can get it into an editable format on your computer, you can go through the document using track changes. You are now going to sit down and read every single word of the document: slowly, carefully and thoughtfully. You will go online and look up the definitions of any legal terms that you do not understand. You can write those definitions in the margins. You can make notes about things that you understand and want addressed and about things that you do not understand. After fully digesting the document, you will either decide to walk away from this job or you will think that this might be doable if the potential employer is agreeable to reasonable changes.

If you wish to go forward, you will now hire an experienced physician employment attorney and will send him or her a copy of your highlighted document with all its notations. You will discuss your concerns. Your attorney will review your document and schedule a follow-up discussion. Your attorney may advise you simply to walk away. Or he may give you a list of items that need clarification or correction. Some issues you identify and some of your attorney’s recommendations will be deal breakers meaning either these changes are made, or you refuse the offer of employment. Others may be that it would be nice if you could get them, but are not that important. With the help of your attorney and your spouse or significant other, if there is one, you will formulate a plan for seeking necessary and desired changes in your employment contract that are reasonable and fair to both parties. Your attorney will help you express your concerns in a language that resonates with the attorney working for your potential employer who will have to give the final approval on any changes to the employment contract.

I will walk you through how I approach these negotiations. I schedule a phone meeting with the individual designated by the potential employer to be their face for the negotiations. My tone is very pleasant and reasonable. I start by saying that my wife and I have carefully read the contract. I have sought the advice of a very competent attorney experienced in physician employment contracts. From these discussions, the following concerns have arisen. If the concern is coming from me, I do not hesitate to say so, but I consider it a good strategy to point out when the concern is coming from my wife or from the advice of my attorney. This is called an appeal to higher authority. It may seem like weakness, but it is a very powerful tool. Used properly, it can tremendously strengthen your position as nothing they say to persuade me will have any impact on how my wife feels about it, especially when it is an issue that is recognized as a reasonable concern for the employee’s wife. When appropriate, I ask for clarification of language in the contract rather than outright changes. Everything that I am asking for needs to be laid out in this first meeting. If you keep coming back with new demands, they may tire very quickly and look for another candidate.

You likely will not get everything you ask for. Just make sure that you get everything you need.

You likely will not get everything you ask for. Just make sure that you get everything you need.

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