With success had come high patient volume and greater complexity, leading to backlogs, longer patient waits, delayed access, staffing problems, billing mistakes, and a host of volume related issues, all affecting patient satisfaction, the doctor and staff’s enjoyment of work, profitability, and other measures of “greatness.”  How could these conditions be alleviated and these good practices made great?

A 1991 book published by Jim Collins entitled Good to Great encompasses five years of rigorous research targeted at identifying common factors which separate good companies from great ones.  One of the hardest questions Collins had to answer was, “Why build a great company at all?  Isn’t a successful company enough?”  His conclusion was, “If you’re doing something you care that much about, and you believe in its purpose deeply enough, then it is impossible to imagine not trying to make it great.”  Collins feels that if you are not compelled to become great at whatever type of work you are engaged in, you are probably engaged in the wrong line of work.  As doctors, we need to know what it takes to build great medical practices, and in comparing my findings (from working with medical practices) with Collins’ research on companies, I discovered many similarities.  Perhaps one of the most significant parallels is that it is easier and more fun to create and work at a great company (practice) than it is to create and work at a good one.  In this article, I will discuss the areas identified by Collins in his research in the context of my experience of working with medical practices.

When I published my book Reengineering the Medical Practice in 1995, one of my motivations was that I felt many of the management principles suggested by experts for improving medical practice performance was flat out wrong.  One of the adages we were taught by our surgical professors was, “The enemy of good is better.”  This was also a widely held belief amongst company managers.  If this were true, going from good to great would be a mistake.  Another adage was, “If it isn’t broken, don’t fix it.”  If this were true, there would be no need for reengineering or continuous quality improvement.  When technology was introduced into medical practices, the suggested applications defied the laws of physics as they applied to workflow and efficiency.  The list of erroneous management principles being taught to doctors was almost endless.  For this reason, I dedicated the early chapters of my book to what I felt were the basic areas on which to focus when attempting to improve practice performance.  I derived many of these from disciplines of companies engaged in manufacturing, and this included workflow, process efficiency, continuous quality improvement, statistics, economics, finance, and other concepts not traditionally taught in medical school.  I have been testing these concepts over the past ten years to determine how they apply to patient, paper, and information flow in a medical practice and what their impact on patient satisfaction, quality, cost, and revenue might be.  It is only recently that the Institute of Medicine has identified these areas as core physician competencies capable of addressing medical errors, quality problems, treatment variation, and high cost in healthcare.  The unchanging principles underlying these concepts have held up in the “real world” and form the foundation for sound practice improvement.

I first quoted from Jim Collins’ “timeless principles” several years ago.  He stated that, “While the practices of engineering continually evolve, the laws of physics remain relatively fixed.”  Collins felt that the principles basic to the great companies he had identified were relevant no matter how much the world changed.  I agree.  Let us take a closer look at some of his findings and discuss the relevance of each one to our practices and our profession.

Level Five Leadership

You could fill a library with books on leadership.  Almost by definition, a good practice has a good “leader.”  In fact, I find that doctors who have built good practices are often leaders in several areas, including their communities, hospitals, and professional associations.  Leadership qualities are difficult to put into words, but words often associated with leaders include: trustworthy, competent, confident, effective, influential, visionary, and attentive listener.

There is no question that building a good practice requires the factors listed above, but in his study, Collins was seeking to identify factors necessary for building something great.  He found that great companies were built by those he termed Level Five Executives.  Collins delineated a hierarchy of five levels of executives: a Level One leader being a highly capable individual possessing many talents, Level Two: a contributing team member, Level Three: a competent manager, and Level Four: an effective leader.  Certainly, a Level Four corporate leader is capable of building a good company, just as a Level Four doctor is capable of building a good medical practice, but building a great company takes a Level Five Executive, and the two characteristics that Collins says differentiate this executive from the others are personal humility and professional will.  The professional will associated with Level Five Executives is not surprising; an executive must be committed and possess the personal resolve to do whatever is necessary in order to make a company great; however, the finding of personal humility as a key leadership factor enabling the building of a great company was unexpected.  The data that Collins found supporting this was overwhelming and convincing.  These findings require an expansion of the set of words on our “leaders list” to include: quiet, humble, modest, reserved, shy, gracious, mild-mannered, self-effacing, and understated – traits not typically mentioned in the same sentence with leadership.  Obviously, for the second list of traits to be an asset, a leader must also possess those on the first list.  As we discuss the other areas Collins found necessary for building a great company (practice), it will become clearer why these Level Five traits are so important.

The Right People

Many practice management experts accept the adage, “People are the most important asset any manager has.”  It is rare to see an article where a successful CEO or doctor does not credit staff as one of the most important factors behind his/her success.  Collins expands this adage, however, citing that it is not people who are a company’s (practice’s) most important asset, but rather, the right people.  This is a subtle, but critical, distinction, one which has been proven over and over again.  Leaders who build great companies universally love what they do, but much of this love has to do with whom they work.  This insight tends to contrast with conventional wisdom.  Most people believe that vision, direction, and strategy come first, but great companies always focus first on what Collins refers to as “getting the right people on the bus, the wrong people off the bus, and then getting everyone into the right seat.”  Only after this is accomplished, should it be determined where “the bus” is going.

Collins’ “right people on the bus” concept has strong applications for building great practices.  It applies to choosing partners, associates, merger candidates, staff, and setting office policies.  Collins found that most of the good companies he selected to compare with great companies consisted of “a genius with a thousand helpers.”  Each had a smart leader who set a vision and then recruited capable people to help attain this vision.  This model is complex, requires considerable bureaucracy and supervision, and encounters difficulty when the vision changes or market realities dictate a change in direction.  This is the point at which many busy, “successful,” medical practices find themselves struggling.  Usually, a doctor does not have the luxury of employing an executive staff or managers to supervise employees, and using traditional models, cannot supervise staff who are “out of sight” (performing clinical and business functions in other areas of the office when s/he is in treatment rooms with patients).  Following the “good to great” model, and getting all the right people on the bus before determining where the bus is going, in conjunction with employing information technology at all office locations, provides the solution.

Every doctor has experienced the agony of having the “wrong person on the bus.”  Most employers are reluctant to fire such employees, but an important point that Collins makes is that this is in the best interest of the employee as well as the practice.  It is a great disservice to everyone in a practice, including the offending employee, to keep the wrong person on staff.  This creates a burden for the employees who are achieving, and it delays the opportunity for the “wrong person” to find a new job for which s/he is the “right person.”  The last thing you want to have happen is to lose the right person because you failed to remove the wrong one.  The “right” people don’t need to be closely supervised because they are self motivated to produce results.  Attitude is more important than skills.  The right attitude cannot be taught, but skills can.  Most doctors have found that when they have the right people with the right attitudes, work is more fun, less supervision is needed, and the practice is more productive.

To go from good to great in the future will require collaboration, teamwork, and group practice.  To accomplish this effectively will require the right people, and they should be recruited before setting a vision or developing a strategy.  Collins’ three recommendations for acquiring and keeping the right people are: 1) If you have any doubts about hiring a person, it is better to keep looking, 2) When you know you need to make a “people change,” take action immediately, and 3) Put your best people on your biggest opportunities, not your biggest problem.  It is often difficult to be certain if someone is the wrong person and should be “removed from the bus.”  To determine this, Collins suggests you ask the following questions:  1)  If you were making a hiring decision, would you hire this person again? – and 2) If this person told you that he or she were leaving to pursue a new opportunity, would you feel terribly disappointed? – or secretly relieved? 

Confronting Facts Without Losing Faith

There is no question that a positive attitude is important to success.  Most successful doctors I know read motivational books and have attended motivational lectures.  Ray Kroc, founder of McDonalds, said that the traits most responsible for his success were persistence and determination.  Persistence, determination, and a positive attitude are critical for success and for going from good to great; however, these traits must be combined with what Collins refers to as “confronting the brutal facts.”  This is the point at which charismatic leaders or “geniuses with a thousand helpers” can run into problems.

Essential to confronting brutal facts is an environment where people have the opportunity to be heard which, ultimately, leads to the truth being heard.  Leaders who are positive, determined, and driven by a vision often have the unintended effect of preventing the brutal facts from emerging because people are afraid to appear as negative or non-team players by voicing these issues.  All companies face adversities, but companies attempting to go from good to great respond differently to adversity.  Their leaders encourage team members to debate facts and confront the realities of the changing environment, and when mistakes are made or things do not work out as planned (the “brutal facts”), they evaluate what went wrong without fixing blame.  Those leading great companies realize that nothing can be more demoralizing than clinging to false hope built on incorrect facts or an inaccurate perception of reality.  Once people have been heard, issues have been debated, and the realities of a changing environment have been considered, cumulative decisions will be better, and the entire team can come together and work in harmony with an absolute conviction that, in spite of adversity, they will triumph in the end.

Passion and Focus

I hear many doctors complain about aspects of practice they don’t enjoy.  The complaint might center on a type of patient, a medical condition, certain treatment procedures, an insurance company, the practice facility, or an employee.  In spite of the fact that, ultimately, it is the doctor’s practice and within his/her power to make any type of change imaginable, it is amazing how many excuses doctors find to maintain the status quo.  Often, this is due to the fear of losing income; however, continuing to do things s/he doesn’t enjoy actually affects earnings negatively over the long term.  Doctors need to know that anything they dislike about their practices can, and should, be changed.

In evaluating companies that have moved from good to great, Collins used three intersecting circles to help a company find its focus.  The first circle represents what you can be “the best in the world at”; the second identifies the economic driver of your business; and the third contains what you are deeply passionate about.  It is hard to be best in the world at very many things, and it is even harder to be great at something without being passionate about it.  Combining what you are good at with what you are passionate about is a major factor in going from good to great.  It also makes work fun for everyone involved.  Economic drivers are beyond the scope of this article, but I can assure you that mindless pursuit of growth is not one.  If you are doing what you are passionate about, and it is something at which you are among the best, the economics will take care of themselves – even if there is no third party coverage.

Technology Accelerator

I was pleased to see that none of the companies studied by Collins that became great credited technology as the primary reason for their greatness.  Technology cannot create a level five leader or turn the wrong people into right ones.  Companies identified as moving from good to great tended to see the role of technology differently from other companies.  Specifically, most felt that it was not the technology itself that made a difference, but rather, the unique application of that technology.

By itself, technology cannot create greatness, or cause decline, but depending on which direction a company is going, it can accelerate either a good or bad direction.  In the case of medical practices, we all have access to the same technology.  The differentiating factor amongst practices is how they apply that technology to improve the areas described in this article as necessary for achieving greatness.

Momentum

Upon seeing a great company, people might ask, “What is the breakthrough that made the most difference?”  Typically, there is no single “breakthrough” that is responsible.  Instead, it is the accumulation of effort in a constant direction which adds up over time.  What this accumulation creates is momentum, and I feel that this is one of the most important factors in the achievement of greatness.  To make a point about the importance of momentum, Collins uses the example of a flywheel measuring thirty feet in diameter, two feet thick, and weighing 5,000 pounds.  Envision a group of people pushing this flywheel in one direction around an axel.  At first, it moves very slowly, and it may take several hours to complete one full rotation.  With sustained effort, however, the speed of the flywheel steadily increases, gaining momentum by building upon work completed earlier.  There is never one big push, or big event, that accounts for the speed, but rapid rotation is eventually achieved through an accumulation of effort over time.  If we apply this same principle to a company, we can say, “Once a company has attained momentum, more can be accomplished with less effort.”  The “flywheel effect” is comparable to the power and leverage made possible through continuous improvement.  With momentum, it is easier for everyone involved to see results and recognize the direction a company is going.  It is easier to build enthusiasm, overcome resistance to change, and attract more of the right people when a company (practice) has momentum.  All of this leads to moving from good to great.

Imagine doing work about which you are passionate and at which you are among the best in the world everyday.  Then, imagine doing this work with the right people, ones who are self-motivated, require little supervision, and you enjoy being around.  Now, imagine that once momentum is achieved, things just keep getting better.  These are the rewards for moving from a good to a great practice.  Since building a great practice requires no more effort than creating a good one, I suggest investigating these ideas further and considering as your next practice goal a move from good to great.