Five Ways to Use Inclusion Behavior to Avoid Practice Management Headaches

Medical practices thrive when the staff is effective and processes are efficient. However, this best case is not always present. The management challenge is to implement change to build a better practice. In any management effort aimed at change, the SWOT analysis (Strengths, Weaknesses, Opportunities, and Threats) recognizes the areas that are least and most under management control. For example, economic conditions have a large effect on the availability of good staff at reasonable wages, but the economy is not a controllable variable. Practice management professionals should exhibit leadership and look to themselves for those things they do have control over and find ways to improve in those areas.

Leadership studies have shown leader behavior to be highly important to organizational success. The way a leader acts can make a large difference in many organizational outcomes. The logic is that leader behavior is an input to the relationship between leaders and their team members. That relationship, known as the leader–member exchange (LMX), is associated with a host of outcomes: good outcomes with a high-quality LMX relationship and bad outcomes with a low-quality LMX relationship. A multitude of factors may affect outcomes, but the LMX relationship has been shown to be right in the middle of inputs and outcomes. LMX can strengthen the relationship between an input and an outcome, weaken the relationship, or even change the relationship from positive to negative and vice versa. Developing and nurturing that LMX relationship is a one-on-one process. A leader develops a unique relationship with each team member. As a result, the exact same behavior and environment can result in differing LMX quality for each leader–member pair (i.e., having five direct reports means having five distinct relationships). Group behavior also exists, but group behavior usually is the aggregate of individual member behaviors. Leaders align individual member behaviors into a cohesive group behavior. Focusing on each individual team member is critical to organizational success.

Leader Behavior

One area of leadership that is (mostly) within the control of the leader is his or her own behavior. If a leader doesn’t show respect, respect is likely not shown to the leader. If a leader doesn’t show gratitude, none may be returned. These are just two ways that researchers have found leader behavior to be key to understanding how team members behave. One of the most important leader behaviors is called inclusion. Five Star Leadership researchers describe inclusion as: ensuring leader and team member have open discussions about decisions affecting the work required. The discussion covers the task goals, processes, resources, obstacles, and other factors, with the team member having ample opportunity to give input.

Inclusion in Interactions with Team Members

Inclusion behavior permeates good leadership activities because it is basic to the trust required for a high-quality LMX relationship that leads to positive outcomes. Inclusion can be used in many situations. Five of these are the most important in interactions with individual team members. To be a leader who understands, internalizes, and implements the inclusion behavior, keep in mind the goal: efficiency of process and effective staff, leading to a great medical practice. This leads to a great leadership experience. Four other leader behaviors are also important: respect, reward, improvement, and modeling. All five behaviors support each other.

Inclusion is the proactive leader behavior that ensures team members are part of the decision-making process for decisions that affect them. There is a wide range of what this can look like in practice. Good leaders use the appropriate style for the situation. For example, bringing on a new medical partner is an important decision affecting team members, but the discussion with the team member is not about whether to bring on a new partner, nor is it about which candidate is best. The discussion is about how the fact that a new partner is coming on board will affect the team member. Let’s say it will affect Alex, the scheduler, by adding another doctor to the scheduling process. Having additional appointments available increases the scheduling workload. How does Alex feel about that? There will be a partner brought on, and there will be an increase in workload. Those are facts. How Max, the office manager, works with Alex will make a difference. This brings up the first of the five recommended important times to use inclusion: when a team member’s workload will change.

How does inclusion play a part in workload change situations? Inclusion shows respect by the leader to the team member. A one-on-one discussion with the team member whose workload is about to change usually brings to the surface tensions that have been brought on by impending change. The main premise of Spencer Johnson’s book Who Moved My Cheese? is that change will happen, and both good things and bad outcomes can come from the change.(1) How a leader implements and manages change makes the difference between good and bad. A leader who discusses what is going to change, why, and what it means to each team member and to the organization will uncover potential problems. Note the word potential . . . these are problems that can now be anticipated, planned for, and even headed off before they occur. For example, Alex, the scheduler, in the sit-down with Max, the office manager, reminds Max that the scheduling software can handle only six partners, unless the practice upgrades to the premium edition. Max might have known that—but imagine what problems could occur if no one mentioned this issue. Or perhaps in the sit-down, Alex, for the first time, lets Max know that the scheduling tasks are already overwhelming. This brings up the issues of capacity, perhaps training, of staffing levels and so on for Max to consider as the team leader. Without a discussion about change, there is little chance of anticipating individual challenges brought about by the change.

Inclusion and Rewards

A second important time to use inclusive behavior as a leader—meaning discussing issues one-on-one with team members—is regarding rewards. Reward behavior involves consciously considering what rewards are supposed to accomplish and how each team member relationship will be affected by the rewards. Rewards are the compensation for work. Rewards can be as straightforward as pay for hours worked, and as intangible as, “It’s a compliment to be working at this practice.” Keep in mind that people view rewards differently. Inclusion will build a rewarding culture respected by the members of the team and effective at molding behavior to achieve success. Practice leaders can ask, “What do you think of the rewards you receive for work?” Leaders coach members by using leading questions such as, “How do you think this compares to other practices?” and “What would you have me change if I could?” The latter question is important to LMX quality: effective leaders emphasize that they have only so much scope, but within that scope they will consider the goals and needs of the individual team member. This type of discussion using inclusion results in arriving at leader–member agreement on: (1) what is important for both leader and team member; (2) where there is intersection; and (3) how that intersection can be exploited and expanded using appropriate rewards. It is possible that a member would rather have extra days off than more pay (for instance, perhaps Alex would like to be able to spend time helping at a child’s school one day a month).

Personal feelings can surface during a discussion of rewards. Max and Morgan, the practice’s radiology technician, are discussing the reward culture, when Morgan says, ‘I don’t feel appreciated here for all of the continuing education I am taking to learn the specialties of technologists.” There are various ways to address this. The key is to know that this feeling exists; otherwise Morgan could decide to work elsewhere as a technologist with Max never knowing why. Voluntary termination (quitting) usually is dysfunctional for an organization, and in this case, Max would then have a hiring process on top of the day-to-day managing of the office.

Inclusion When Improvement Is Needed

The third time inclusion as a leader behavior is useful is when the leader sees that improvement is needed. Like the need for a discussion when a change is coming, improvement discussions are broad enough to encompass the why, what, where, when, and who of improvement. Discussing the “why” requires a respectful attitude, because criticism of the member might be involved. The behavior of respect involves listening and empathy without judgment. A high-quality LMX relationship cultivated over time will keep the “disrespect” element at bay, because the relationship is based on trust. A respectful discussion will be honest about the problem that needs to be solved. Improvement has several aspects worthy of an inclusive discussion.

One aspect is the leader’s need for change, such as better skills, more knowledge, improved communication, or certain certifications. These improvements are needed to help the leader achieve organizational goals. An inclusive discussion is begun by the leader stating what it is that he or she is trying to accomplish. Max says, “I need technicians to become radiologic technologists, so we can be better at specific diagnostic tests and not have to refer out. Referring out costs the practice income we want kept in-house.” Morgan, a technician, could be highly motivated by this idea. The other aspect of inclusion regarding improvement is the “improvee’s” point-of-view. Yes, Morgan could be highly motivated by this idea; on the other hand, perhaps she is not motivated by it at all. Further discussion will bring this out. The improvement behavior is not one-sided; the discussion should touch on what the team member would value as improvement even if that is not directly related to the challenges the leader is facing. For example, Alex (scheduler) wants to improve his knowledge of Microsoft Office beyond the job-related skills. A good leader interested in LMX quality would figure out a way to help with that personal goal. A wide-ranging discussion need not be lengthy, but open-ended questions by the leader and answering member questions creates better buy-in to the proposed improvement while improving LMX quality.

Inclusion and Employees’ Personal Lives

The fourth inclusion moment involves discussing a team member’s personal life. Many employees are reluctant to discuss problems they may be having at home. They can be just as reluctant to discuss their hopes and dreams. The leadership issue is that understanding problems can inform discussions on productivity, and understanding hopes and dreams informs discussions on rewards and retention. On the negative side, low-quality LMX relationships are associated with low productivity, absenteeism, drug and alcohol abuse at work, and dishonesty. Inclusive discussions about personal issues can increase LMX quality, which is associated with decreasing these negative personnel issues.

There is a trick to this: trust must come over time for the member to be open about these issues. Respect behavior is critical. If a leader practices inclusion and respect in the other areas of member engagement, this can build that trust-based relationship. These discussions need not be in-depth to accomplish the practice leader’s goals. The important outcome is that the team member trusts that the leader understands the problem and, if there is a fix, the leader will try to make it happen. For example, the reason Alex wants to help at school and be better at Microsoft Office is that Terry, their 12-year old, is having trouble with writing reports that are assigned each month. Alex needs to know more about Excel to help with the math parts of Terry’s reports, and Alex wants to be at school with Terry when the report is presented.

Inclusion and Goal Setting

The fifth important use of inclusion by leaders to improve organizational outcome is goal setting. Goals are a great way for an organization to plan their success. In a medical practice, success measures include safety, financial soundness, patient satisfaction, and a good work environment, among others. An excellent management practice is to create goals for outcomes that are SMART (Specific, Measurable, Achievable, Relevant, and Time-bound). SMART goals are developed with each team member having responsibility for all or part of the goal. A member motivated to achieve the goal will likely act in ways more likely to achieve that goal. Five Star Leadership research is based on the premise that a leader’s job is to get others to do the things the leader needs doing. Inclusive discussions with members affected by the goal will improve motivation for achievement.(2)

A perfect organizational leadership process would have the team creating the goals, the way to achieve the goals, the measures necessary to achieve the goals, and the timeline. In reality, goals usually are created by leaders and set before members. Inclusion can still be used. Max’s boss says, “The practice needs a zero-incident safety record.” Max has no choice but to relay this to the team. Max could announce the need and expect zero incidents. Or Max could announce the goal, then meet with members one-on-one to design SMART goals to achieve the overall goal. This is especially important if the need creates goals that are not achievable with the status quo. “How can I have no safety problems if we don’t stock enough of the disposable safety equipment I use in testing?” Morgan asks. Inclusive discussions are not “gripe sessions,”—they are, rather, a way to get input and demonstrate respect for team members’ opinions. A constant griper has a different problem, which also can be addressed starting with an improvement discussion. Few people like top-down driven goals, but they are a reality. An effective team leader will take these goals and massage them into team goals. Inclusion will help get buy-in by team members, leading to a greater chance of success.

Conclusion

This article has discussed three key concepts. The first, the quality of the LMX relationship, is important to consider as a leader. The second concept is that a leader must be aware of team member needs. Finally, the third concept is that leaders should use inclusion behavior consistently when working with team members to accomplish organizational goals. Leaders must be trusted when having one-on-one discussions with team members. Leadership is a skill that can be learned, honed, and implemented. Inclusion is a leader behavior of first-tier importance to a medical practice leader.

References

1. Johnson S. Who Moved My Cheese? New York: G. P. Putnam and Sons; 1998.

2. Smith D. Think “inclusion” to build teamwork. The Journal of Financial Planning. February 2018:18-19. https://lmxpro.com/images/FSLConsumerArticles/Feb-2018-JFP-Inclusion.pdf . Accessed 1/14/2019.