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A MANAGER’S CHARGE: IMPLEMENTING CHANGE EFFECTIVELY


This case was prepared by Leigh W. Cellucci, Carla Wiggins, and Wendy Peterson, all at Idaho State University,
and is intended to be used as a basis for class discussion. The views represented here are those of the case authors
and do not necessarily reflect the views of the Society for Case Research. Author’s views are based on their own
professional judgments.

Introduction
Rochelle Anderson, business manager at the Idaho Women’s Clinic was excited and
anxious about her assignment. The Idaho Women’s Clinic physicians’ 2006 strategic retreat had
just ended and the work accomplished had been more productive than she had hoped. First, all
five physician partners were there and they were able to work as a team and write the mission
statement. Second, they had agreed that a central patient database and a central billing office
needed to be set-up. Then, announcing their confidence in Rochelle, they delegated the
implementation of the database and central billing office to her. Dr. Carter stated, “We want to
practice medicine, not run an office. Rochelle, we depend on you for that.” Dr. Cochran,
President of the Clinic Board and one of the charter physicians of the partnership, agreed.
“Rochelle, you have my total support in this endeavor to centralize business operations. You
figure out how best to choose what database system should be chosen and how the billing office
should be set up.”
As she thought more about the assignment, Rochelle worried that perhaps the physicians’
confidence in her might be overstated. Many of the clinic physicians had staff that had been with
them for most of their years in practice, including the years prior to the partnership formation.
Staff for the three original partnership physicians averaged over 15 years of service, and one had
worked for the same physician for 30 years. How was she to convince these staff “old-timers”
that it was time to change?

The Clinic
The Idaho Women’s Clinic was founded in 1997 as a three-physician partnership. Over
the last ten years, the Clinic had earned the reputation of providing “best practice medicine” to
its patients. The physicians were leading innovators in southeastern Idaho in women’s health
care, and patients reported that they received excellent OB/GYN care. Consequently, patient
demand had encouraged the original three physicians to grow their practice. Also, because the
Clinic operated in Idaho, which ranked 49th among states in physicians per capita, more
physician services were needed for the rural community-at-large. Since the Clinic’s
establishment in 1997, two more physicians had joined the practice along with one physician
assistant, three nurse practitioners, and two nurse midwives. The end result was an incorporated
group practice that had grown quickly. The Clinic was currently searching for two more
physicians to join the practice and they were discussing expanding the nurse midwife program.
This expansion, however, had created an organizational structure in which each physician
had his/her own staff, billing center, and patient medical charting system (see Figure 1). Each
physician also had his/her own waiting room with its own separate entry, different receptionist,
and different nursing staff. The aggressive growth rate had resulted in a Clinic that was actually
five separate independently operating practices. The reporting structure of office personnel
reflected this independent arrangement. While Rochelle reported to the President of the Idaho
Women’s Clinic (Dr. Cochran), none of the office managers reported to her. Each one reported
to her respective physician with the nurses and office personnel reporting to the office managers.
The structure had evolved informally and the organizational chart reflected this informal
arrangement. For example, Dr. Sutherland’s nurse had requested and received permission to
report directly to her physician and, unlike the other office arrangements, bypass the office
manager.
Nonetheless, the overall growth and evolving organizational structure of the Clinic did
not affect the day-to-day operations of the office staff. Since the Clinic was essentially a
structure of silos, staff members between separate doctor’s offices did not regularly interact with
one another about work. Rather, staff interaction was limited to lunching together and discussing
their social plans for the weekend. Clinic operations, filing systems, and billing issues were not
discussed precisely because each physician’s office had an office manager that followed her own
office protocol. The only change noticed by the staff was the growth of staff in other offices.
There simply were more people to get to know and see.
Rochelle Anderson
Rochelle had been hired six years ago as an administrative assistant for the Clinic. At
that time, she had earned an Associate Degree in Medical Assisting from the State University,
and she knew that she was prepared to answer the phone, schedule appointments, and help with
billing. She quickly learned that her responsibilities in the Clinic exceeded her training. She was
also expected to manage the call schedule, put together the agenda for the physician meetings,
take the minutes for the meetings, and offer sound advice regarding office business practices.
Rochelle responded well to work demands and she learned that she liked her job. She found the
work to be interesting and challenging and the staff members to be friendly and encouraging.
She and the staff agreed that her top priority was to help manage the staff increase at the Clinic
and ensure that scheduling, billing, and day to day operations were not negatively affected by
future growth.
Rochelle was well liked by the Clinic staff and the physicians. She excelled in her work,
was personable and friendly, and she was known as the “home grown star” around the Clinic.
Dr. Cochran was happy to note, “We are proud of Rochelle. She came to us a few years ago,
eager to prove herself. And yes, she has surpassed our expectations. In fact, we agreed two years
ago to help her grow in this position. The Clinic pays for her tuition to earn a Bachelors degree
in Healthcare Administration from the State University. And she is doing great. Rochelle is a
straight “A” student.” Dr. Cochran paused and smiled, “But,” he added, “We didn’t expect
anything less of our star.”
Dr. Carter added, “She is the one who got us to have the first strategic planning retreat.
And, that was a success. The doctors got out of the Clinic and spent the entire day at a The Hot
Springs Resort. We really experienced a retreat, and it was the first time I saw us as a team of
physicians, a group. I used to think of us as physicians who merely shared office space.”
Dr. Cochran spoke, “Rochelle got us to draft a mission statement—she wanted us to
define who were are and what we want to be remembered for regarding our work. I liked
thinking about us as a group. And that helped me to understand that, as a group, we need
Rochelle to take the lead in initiating measures to help create office practice efficiencies that
makes sense.”

The Clinic Culture


Like many solo practice medical offices, Idaho Women’s Clinic had a strong
organizational culture based on friendly, patient-oriented attitude, and seniority. The culture was
positive and people worked well together. There were no written job descriptions; staff just did
what needed to be done. The primary mission of the office staff was to “Help the women be
comfortable, welcomed, and well cared for.” If there was a question about office practice, the
staff member with the most seniority was consulted. Staff members respected the years of
service of others, and most planned to be employed at the Clinic throughout their career.
Five office managers were in charge of their respective physician practices. Over the
years, each office had developed its own protocol regarding patient accounts and billing. For
example, each filing system had been created by the individual managers; and as a result, there
were five different coding procedures for insurance names, insurance adjustments, and patient
payment codes. Similarly, there were five different procedures for billing. Each office manager
was in charge of her specific physician’s billing, except for common function procedures, such
as bone density testing. One of the office managers was in charge of this billing for all patients;
hence, the five office managers had some, although limited opportunity to interact with one
another regarding patient care.
Apart from brief work interactions, the five office managers had the opportunity to see
one another informally as there was a common break room for the entire Clinic staff. It was not
uncommon to see the managers together, laughing over the latest joke or talking about what they
had recently watched on television. They genuinely liked and respected one another. Along
with the common break room, the Clinic also had a common conference room. Usually,
physician meetings with their individual staff were held there. Few, if any, overall Clinic staff
meetings were ever held as there was little need to do so.
Staff members felt as though they were treated as “family,” and they prided themselves
on treating one another as “family.” Rarely was there negative conflict in the office. If a new
staff member did not fit, he or she was quickly replaced. However, replacements were few. Most
new staff members wanted to stay as the environment was positive. They were encouraged to
interact with the patients; their talking with an expectant mother or holding her hand if she was
concerned about an upcoming procedure made them know they were making a significant
contribution.
The physicians were quick to recognize good work efforts of the staff. If a staff member
performed a noteworthy action, the physician would recognize the effort. This recognition for a
job well done reinforced the positive culture of the Clinic. Thus, the daily work environment,
while stressful because of the nature of healthcare, was upbeat as well as productive. Clinic staff
members knew that their jobs were secure and they knew that the physicians appreciated their
work in the office. Further, they got to do their work without the physicians micromanaging the
business operations. As Dr. Carter said, the doctors wanted to practice medicine; they were not
interested in business operations.

The Clinic Mission Statement


The culture is reflected in the Clinic mission drafted by the physicians at the retreat:
The Idaho Women’s Clinic mission is to provide compassionate healthcare for
women in Southeastern Idaho. To accomplish this, we are dependable to our
patients, staff, family, and professional colleagues. We strive to have a positive
impact on the wellness of patients. We act responsibly, both ethically and
financially toward our patients, staff, families and colleagues. We adopt best
practice medicine in our clinic and adhere to a set of common values:

• We have Integrity
• We maintain Professional Excellence
• We encourage Collegial Support
• We provide a Safe Environment

The Five Office Managers


Each physician had an office manager who was in charge of billing, secretarial
operations, and supervising the clerical staff. Laura Beasley, office manager for Dr. Cochran,
had worked for him prior to the Clinic’s founding and had 30 years experience as his office
manager. Laura’s entire career had been spent working for Dr. Cochran. In fact, she had begun
working in the office while in high school, and she knew that this office was where she wanted
to stay. She strived to implement Dr. Cochran’s wishes regarding how the office should be
operated, and she was encouraging of Rochelle and her efforts as well. “We like to grow our
own here,” she said.
Laura knew how to run an office effectively. She was intelligent, assertive, and quick to
speak up to support Clinic staff. She was the informal leader of the office managers. If there was
an issue that needed to be resolved, the other office managers came to Laura. She enjoyed
serving as the leader and often said that she did not plan to retire. She was too needed at the
Clinic to make sure that patients were seen and the bills were paid. Everyone respected Laura,
but she could be intimidating if she did not think the staff members were prioritizing their work
properly. For instance, if a patient needed to schedule an ultrasound, the office secretary was to
schedule the procedure with the patient immediately. Laura did not believe that a patient should
wait unnecessarily. Thus, the secretary should expect to be interrupted from any paperwork task
to give attention to the patient. As Laura was known to say, “The patients pay our bills; let’s
make sure they know we care about them!”
Laura commonly stayed late several evenings a week to work on patient accounts. She
enjoyed the billing aspect of the job and was pleased to know that all was in order in Dr.
Cochran’s office at the end of the day. While Laura usually supported Rochelle and wanted her
efforts to be successful, she was always concerned about how changes might directly affect her.
She liked being the leader; change might represent a potential position demotion. She wanted to
know how any change would directly affect her position of authority. After all, she had been
there for 30 years.
Liz Johnson was the office manager with the second highest seniority. She had served as
Dr. Sutherland’s office manager for 25 years and she was often seen lunching with Laura. Liz
admired Laura and looked to Laura for leadership. However, Liz’s work practices were different
from the other office managers as she was computer adverse. “I do not excel at Excel,” Liz was
heard to say. In fact, instead of setting up patient report files in Excel, Liz handwrote the reports
for each patient. The other office managers had set up an Excel based report form so that they
could fill in information on the standardized form. This saved time for the other office managers.
Because Liz did not adopt this practice for patient reporting, she spent about 20 more hours per
week on the task than did the other office managers. It was not uncommon for Liz to be working
late in the night, handwriting patient reports. Liz said that she would rather stay late than change.
“I like doing things my own way; it may take me more time, but that is the way I like it.” Liz did
not like change.
Kelly Robinson had served as the office manager for Dr. Davids for 20 years. She was
known for being the “Missouri Manager.” She insisted that staff demonstrate their work to her.
She did not want them to tell her what the issue was; she wanted to be shown. Kelly learned best
by hands-on lessons, and any new task had to be demonstrated before she would adopt it.
Kelly spent most of her time scheduling patients and answering the phone. In addition,
when the Clinic was incorporated, Kelly had been assigned the billing for accounts payable. She
made certain the rent and salaries were paid for Clinic employees. Kelly was proficient in these
tasks, but she did not master them until she was shown how to bill and account for expenditures
for rent and salaries. Dr. Davids recalls, “Kelly wants to see it first. In fact, I gave her the
nickname, ‘Missouri Manager.’ She wants to be shown. But, once you show her, there is no one
who can do the work better.”
Kelly had developed a good working relationship with Ted Bower, the computer software
trainer. Ted had visited the office several times to show Kelly how to work the accounting
software package. He was overhead to have said, “Kelly is hesitant to adopt new programs at
first. I call her the ‘Heck No lady.’ But, if I take the time to show her why one package is better
than another, she quickly gets the hang of it.” Their meetings resulted in the two becoming
friends and Kelly and Ted were often seen trying out new computer updates. They also
discovered their mutual enjoyment of golfing and the two played occasionally at the local
community golf course.
Jennifer Hartman was the office manager for Dr. Carter and joined the Clinic ten years
ago, the year it was incorporated. She had previous experience in other medical offices before
joining the group. Jennifer was a team player and was usually the first to say, “I want to learn
how to do that.” She was well-liked and was known as a good communicator. Few problems
existed in Dr. Carter’s office because of Jennifer’s ease with explaining and teaching staff how to
do the work properly. Jennifer wanted to grow, both professionally and personally. Of all the
office managers, Jennifer was the most excited about any changes in office practices, primarily
because she did not like doing office manager work along with a receptionist’s work. She saw
that change might offer her professional growth.
Jennifer was also well liked by her staff because of her excellent communication skills
and she was very positive with the staff. Her positive attitude was contagious. When Jennifer
spoke of a task, she was known to roll up her sleeves and say, “Let’s get this done!” She made
learning something new fun, and she was ready to support and compliment her staff’s efforts.
Alice Thompson had been with the Clinic for two years. She served as the office manager
for Dr. Reynolds, the most recent physician partner. Alice had over 25 years of experience
working as an office manager. Prior to joining the Clinic, she had served as an office manager in
a solo practice. That physician had retired and Alice learned that she needed to learn how to
change to survive. Regarding her work habits, Alice was known for her attention to detail. Few
events occurred in the Clinic without Alice’s noticing them.
Alice had recently spoken with Rochelle to discuss patient record keeping practices. She
found it troublesome if, for example, a patient had seen Dr. Reynolds as a new patient and then
would later go to Dr. Sutherland to be seen again as a new patient. This occurred because each
office was independently run; each had its own fax number, its own phone number, and its own
Suite number in the Clinic complex. Being seen over and over again as a new patient was
inefficient because new patients took more time for the physician and a new patient visit was
more costly to the patient. Furthermore, Alice was concerned that the patient could practice
“doctor hopping,” by seeing one physician after another to receive more prescriptions than she
safely should receive. Or, “doctor hopping” could result in a patient not paying any of her bills
for extended periods of time as she would be seeing one doctor after another as a new patient,
and the office manager would not be alerted of the patient’s payment history.
To elaborate, recently Alice realized that one patient had been a patient with several of
the physicians in the clinic. Alice had overhead the patient comment on the waiting room décor
in Dr. Reynolds’ office as having the best color scheme. Then, she continued to describe some
of the other physician’s waiting rooms. Alice was curious as to why this patient would even
know this information and contacted each office to find out if she had been a patient with any of
the other doctors. It took time to learn about the patient’s history because of the different
protocols for patient record keeping in each office. Dr. Sutherland, for example, documented
patients by number; Dr. Cochran documented patients by name. Drs. Davids, Carter, and
Reynolds documented patients by both name and number. After taking the time to track the
patient’s records, Alice learned that this patient had indeed visited three of the five physicians
with the last six months. Her detective work identified a troublesome problem for the Clinic.
Healthy patients need not set up appointments with a different OB/GYN every two months. This
was not only a patient problem to be dealt with by the physicians, but also it raised protocol
issues regarding the current structure of patient databases. Alice was ready for a change.

The Patient Database and Central Billing Office


As Rochelle learned more about healthcare administration in her classes at the State
University, she began to think about how the inefficiencies in the Clinic could be addressed. The
first change that needed to occur was the creation of the central patient database because no one
could track a patient without contacting each of the separate offices. A central patient database
would address this problem. Also, a central patient database would address the separate office
protocols regarding patient record keeping.
The second change addressed the different coding systems each office employed. Patient
files could not be merged into one system as each office used different labels for patient payment
codes, insurance codes, and insurance adjustment codes. For instance, Dr. Reynolds’ office
identified insurance codes by the insurance company’s name. Dr. Carter’s office identified them
by the employer name. Rochelle knew that one system of coding needed to be implemented and
she also knew that this database would have to be built from the ground up. A new database
software system was needed.
Further, the Clinic paid five office managers to supervise office staff, direct billing and
coding, and to perform secretarial tasks to ensure excellent patient care. There was indeed
redundancy with five office managers and the inefficiencies created by the separate office
protocols. Rochelle knew that the Clinic’s hiring an office manager for each new additional
physician would be unnecessarily costly for the Clinic and might result in even more inefficient
office protocols. She was aware that effective change would require transformation in the
organizational structure so that the office managers would work for the Idaho Women’s Clinic as
opposed to each working for a specific physician who happened to be in a group practice. She
thought actual written job descriptions could help to identify job responsibilities and aid with the
central office establishment, as would reorganization of the personnel reporting structure.
Rochelle wanted to live up to the Clinic physicians’ confidence in her abilities, but she
knew that it would be a test of her management skills to create a positive environment for the
change and to implement the changes effectively. She also knew from her management classes at
the State University that people tend to resist change. Her success was dependent upon
persuading the office managers.
Rochelle opened her laptop computer and settled in on the retreat site veranda. She
opened her Word file that contained the newly written mission statement. As she read she
highlighted the phrases noting that the Clinic is dependable to the staff, acts ethically to the staff,
and encourages collegial support. Rochelle opened a new file and labeled it, “Change Plan.”
She copied and pasted the mission statement into the new file and typed the following:
Goals of the Change Plan
(1) Get the office managers on board with the need for the changes;
(2) Get the office managers to adopt central patient database and billing office;
(3) Get the office managers to understand that while their job descriptions may change, their
jobs are secure at the Clinic.

Rochelle paused and thought, “Now, how do I accomplish these goals?”


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