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THE SOCIETY FOR CASE RESEARCH _______________________

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.

Cochran). and it was the first time I saw us as a team of physicians. We really experienced a retreat. none of the office managers reported to her. unlike the other office arrangements. the overall growth and evolving organizational structure of the Clinic did not affect the day-to-day operations of the office staff. filing systems. Cochran was happy to note. The Clinic pays for her tuition to earn a Bachelors degree in Healthcare Administration from the State University. Dr. put together the agenda for the physician meetings. Carter added. different receptionist. In fact. Sutherland’s nurse had requested and received permission to report directly to her physician and. Each one reported to her respective physician with the nurses and office personnel reporting to the office managers. Rochelle responded well to work demands and she learned that she liked her job. schedule appointments. Rochelle Anderson Rochelle had been hired six years ago as an administrative assistant for the Clinic. Rather. bypass the office manager. had created an organizational structure in which each physician had his/her own staff. eager to prove herself. Nonetheless. Cochran paused and smiled. and different nursing staff. a group. and billing issues were not discussed precisely because each physician’s office had an office manager that followed her own office protocol. There simply were more people to get to know and see. staff members between separate doctor’s offices did not regularly interact with one another about work. billing. She found the work to be interesting and challenging and the staff members to be friendly and encouraging. was personable and friendly. The doctors got out of the Clinic and spent the entire day at a The Hot Springs Resort. Dr. and patient medical charting system (see Figure 1). and offer sound advice regarding office business practices.This expansion. “She is the one who got us to have the first strategic planning retreat. take the minutes for the meetings. She was also expected to manage the call schedule. And. She and the staff agreed that her top priority was to help manage the staff increase at the Clinic and ensure that scheduling. and help with billing. Rochelle is a straight “A” student. Since the Clinic was essentially a structure of silos. Clinic operations. and she knew that she was prepared to answer the phone. The structure had evolved informally and the organizational chart reflected this informal arrangement. “But. She came to us a few years ago. that was a success. and she was known as the “home grown star” around the Clinic. Each physician also had his/her own waiting room with its own separate entry. “We didn’t expect anything less of our star. I used to think of us as physicians who merely shared office space. however.” Dr. The only change noticed by the staff was the growth of staff in other offices. And yes. we agreed two years ago to help her grow in this position.” Dr. She excelled in her work. And she is doing great. The aggressive growth rate had resulted in a Clinic that was actually five separate independently operating practices. While Rochelle reported to the President of the Idaho Women’s Clinic (Dr. At that time. “We are proud of Rochelle. For example.” he added. She quickly learned that her responsibilities in the Clinic exceeded her training. she has surpassed our expectations. staff interaction was limited to lunching together and discussing their social plans for the weekend. The reporting structure of office personnel reflected this independent arrangement. she had earned an Associate Degree in Medical Assisting from the State University.” . billing center. Rochelle was well liked by the Clinic staff and the physicians. and day to day operations were not negatively affected by future growth.

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

While Laura usually supported Rochelle and wanted her efforts to be successful. Cochran. office manager for Dr. change might represent a potential position demotion. and professional colleagues. She was intelligent. As Dr. Laura’s entire career had been spent working for Dr. the office secretary was to schedule the procedure with the patient immediately. and supervising the clerical staff. and quick to speak up to support Clinic staff. She was the informal leader of the office managers. families and colleagues.” she said. let’s make sure they know we care about them!” Laura commonly stayed late several evenings a week to work on patient accounts. staff. Thus. both ethically and financially toward our patients. had worked for him prior to the Clinic’s founding and had 30 years experience as his office manager. She enjoyed the billing aspect of the job and was pleased to know that all was in order in Dr. She was too needed at the Clinic to make sure that patients were seen and the bills were paid. “We like to grow our own here. Cochran’s wishes regarding how the office should be operated. “The patients pay our bills. Laura knew how to run an office effectively. Cochran. She liked being the leader. we are dependable to our patients. the secretary should expect to be interrupted from any paperwork task to give attention to the patient. secretarial operations. they were not interested in business operations. For instance. 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. She enjoyed serving as the leader and often said that she did not plan to retire. To accomplish this. she was always concerned about how changes might directly affect her. She wanted to . the doctors wanted to practice medicine. staff. We strive to have a positive impact on the wellness of patients. If there was an issue that needed to be resolved. Carter said. family. She strived to implement Dr. she had begun working in the office while in high school. Laura did not believe that a patient should wait unnecessarily. We act responsibly. but she could be intimidating if she did not think the staff members were prioritizing their work properly. Everyone respected Laura. and she was encouraging of Rochelle and her efforts as well. the other office managers came to Laura. Laura Beasley. and she knew that this office was where she wanted to stay. assertive. In fact. if a patient needed to schedule an operations. As Laura was known to say. Cochran’s office at the end of the day. 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.

it may take me more time. In addition. instead of setting up patient report files in Excel. The other office managers had set up an Excel based report form so that they could fill in information on the standardized form. Carter’s office because of Jennifer’s ease with explaining and teaching staff how to do the work properly. Kelly learned best by hands-on lessons. Sutherland’s office manager for 25 years and she was often seen lunching with Laura. “Kelly is hesitant to adopt new programs at first. primarily because she did not like doing office manager work along with a receptionist’s work. Jennifer wanted to grow.” Liz did not like change. It was not uncommon for Liz to be working late in the night. the computer software trainer. They also discovered their mutual enjoyment of golfing and the two played occasionally at the local community golf course. she had been there for 30 years. 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. She did not want them to tell her what the issue was. Kelly was proficient in these tasks. Kelly had been assigned the billing for accounts payable.’ She wants to be shown. “I like doing things my own way. Liz Johnson was the office manager with the second highest seniority. there is no one who can do the work better. She had previous experience in other medical offices before joining the group. Jennifer was a team player and was usually the first to say. Because Liz did not adopt this practice for patient reporting. Liz’s work practices were different from the other office managers as she was computer adverse. Liz said that she would rather stay late than change. He was overhead to have said. Davids for 20 years. Of all the office managers. Carter and joined the Clinic ten years ago. and any new task had to be demonstrated before she would adopt it. “I do not excel at Excel. Liz handwrote the reports for each patient.know how any change would directly affect her position of authority. the year it was incorporated. After all. Ted had visited the office several times to show Kelly how to work the accounting software package. I call her the ‘Heck No lady. Davids recalls. she wanted to be shown. “Kelly wants to see it first. Kelly spent most of her time scheduling patients and answering the phone. she spent about 20 more hours per week on the task than did the other office managers. But. This saved time for the other office managers. In fact. “I want to learn how to do that. Few problems existed in Dr. once you show her. both professionally and personally. but she did not master them until she was shown how to bill and account for expenditures for rent and salaries. Jennifer Hartman was the office manager for Dr.’ But. Kelly Robinson had served as the office manager for Dr. She saw that change might offer her professional growth. She had served as Dr. She was known for being the “Missouri Manager.” Kelly had developed a good working relationship with Ted Bower. but that is the way I like it. However. when the Clinic was incorporated. Jennifer was the most excited about any changes in office practices. Dr. I gave her the nickname. handwriting patient reports.” She was well-liked and was known as a good communicator. ‘Missouri Manager. . She made certain the rent and salaries were paid for Clinic employees. if I take the time to show her why one package is better than another.” Liz was heard to say.” She insisted that staff demonstrate their work to her. In fact. Liz admired Laura and looked to Laura for leadership.

This was not only a patient problem to be dealt with by the physicians. documented patients by number. and its own Suite number in the Clinic complex. A central patient database would address this problem. Alice had over 25 years of experience working as an office manager. Davids. To elaborate.Jennifer was also well liked by her staff because of her excellent communication skills and she was very positive with the staff. a patient had seen Dr. Then. for example. Prior to joining the Clinic. After taking the time to track the patient’s records. Alice was known for her attention to detail. Healthy patients need not set up appointments with a different OB/GYN every two months. Furthermore. she had served as an office manager in a solo practice. . Alice was concerned that the patient could practice “doctor hopping. she was known to roll up her sleeves and say. recently Alice realized that one patient had been a patient with several of the physicians in the clinic.” by seeing one physician after another to receive more prescriptions than she safely should receive. When Jennifer spoke of a task. Her detective work identified a troublesome problem for the Clinic. she continued to describe some of the other physician’s waiting rooms. Also. and the office manager would not be alerted of the patient’s payment history. Reynolds’ office as having the best color scheme. It took time to learn about the patient’s history because of the different protocols for patient record keeping in each office. 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. each had its own fax number. That physician had retired and Alice learned that she needed to learn how to change to survive. Dr. but also it raised protocol issues regarding the current structure of patient databases. its own phone number. Alice Thompson had been with the Clinic for two years. “Let’s get this done!” She made learning something new fun. she began to think about how the inefficiencies in the Clinic could be addressed. Carter. Alice had recently spoken with Rochelle to discuss patient record keeping practices. Reynolds. Regarding her work habits. the most recent physician partner. Alice was ready for a change. Few events occurred in the Clinic without Alice’s noticing them. and she was ready to support and compliment her staff’s efforts. “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. She served as the office manager for Dr. and Reynolds documented patients by both name and number. Cochran documented patients by name. Or. She found it troublesome if. a central patient database would address the separate office protocols regarding patient record keeping. The Patient Database and Central Billing Office As Rochelle learned more about healthcare administration in her classes at the State University. Her positive attitude was contagious. 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. This occurred because each office was independently run. Drs. for example. Alice learned that this patient had indeed visited three of the five physicians with the last six months. Sutherland to be seen again as a new patient. 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. Reynolds as a new patient and then would later go to Dr. Sutherland. Alice had overhead the patient comment on the waiting room décor in Dr. Dr.

(3) Get the office managers to understand that while their job descriptions may change. insurance codes. 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. Patient files could not be merged into one system as each office used different labels for patient payment codes. There was indeed redundancy with five office managers and the inefficiencies created by the separate office protocols. As she read she highlighted the phrases noting that the Clinic is dependable to the staff. She also knew from her management classes at the State University that people tend to resist change. Rochelle opened a new file and labeled it. their jobs are secure at the Clinic. Dr. Her success was dependent upon persuading the office managers. the Clinic paid five office managers to supervise office staff. (2) Get the office managers to adopt central patient database and billing office. and to perform secretarial tasks to ensure excellent patient care. Rochelle opened her laptop computer and settled in on the retreat site veranda. and insurance adjustment codes.The second change addressed the different coding systems each office employed. “Change Plan. Further. A new database software system was needed. “Now. 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. She opened her Word file that contained the newly written mission statement. direct billing and coding.” 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. Carter’s office identified them by the employer name. Reynolds’ office identified insurance codes by the insurance company’s name. 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. acts ethically to the staff. and encourages collegial support. For instance. Rochelle paused and thought. Dr. Rochelle wanted to live up to the Clinic physicians’ confidence in her abilities. how do I accomplish these goals?” . 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. 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.


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