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 Contents | vii

Employee Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Physician Recruitment, Retention, and Resource Enhancement . . . . . . . . . . . . 166
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Chapter 6 Marketing Healthcare Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .171
Roberta N. Clarke, MBA, DBA
Marketing Mission and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
The Competition Defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Business-to-Business Marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Derived Demand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Consumer Behavior: Availability of Information . . . . . . . . . . . . . . . . . . . . . . . . 182
Consumer Behavior: Information Search and Use . . . . . . . . . . . . . . . . . . . . . . . 183
Consumer Behavior: Integrity and Validity of Information . . . . . . . . . . . . . . . . 185
Consumer Behavior: The Role of Digital Communication . . . . . . . . . . . . . . . . . 186
Consumer Behavior: Adoption of Innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Differentiation: Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Differentiation: Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Differentiation: Price. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Other Sources of Differentiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Customer Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Data-Driven Marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Chapter 7 Public Health and Private Physician Medical Practice Preparedness:
Can We Be Medically Prepared for the Next Disaster? . . . . . . . . . . . . . . . .199
Denise O’Farrell, MPH; Howard L. Smith, PhD; Keri D. Black, PhD, CFNP
Annette Phillipp, PhD, MPH; Lawrence F. Wolper, MBA, FACMPE
David N. Gans, MSHA, FACMPE; Neill F. Piland, PhD
Historical Relationships Between Public Health
and Medicine Related to Emergency Preparedness . . . . . . . . . . . . . . . . . . . . 200
Creation of the National Bioterrorism Hospital Preparedness Program . . . . . . . 202
The Level of Interaction, Communication, Cooperation, and Training that
Currently Exist Between Public Health and Medical Private Practice . . . . . . 206
The Primary Care Setting as a Key in Disaster Preparedness and Response . . . . 208
Level of Success in Medical Practices’ Preparedness to Interact
with Public Health and Perform During Times of Planning and Crisis . . . . . 211
Improvements that Should Be Made in Emergency Preparedness
and Requirements Essential to Implementation. . . . . . . . . . . . . . . . . . . . . . . 212
Implications for Healthcare Practice and Research . . . . . . . . . . . . . . . . . . . . . . . 213
Toward Enlightened Medical Care in Time of Disaster . . . . . . . . . . . . . . . . . . . . 216

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 viii | Contents

Section II Monitoring and Controlling Physician Organizations . . . . . . . . . . . . . . . . . . . . .219

Chapter 8 Physician Practice: Organization, Management, and Operation . . . . . . . . . . .221
Michael J. Kelley, MBA, CMPE; Steven Falcone, MD, MBA
Stephen G. Schwartz, MD, MBA; Richard D. Norwood, CPA, FHMA, MBA
Forms of Physician Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Healthcare Funding Plan Evolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Operational Aspects of Physician Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Evaluation of Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Financial Benchmarking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Chapter 9 Accounting and Budgeting for Medical Practice Managers . . . . . . . . . . . . . . .247
Steven M. Andes, PhD, CPA; David N. Gans, MSHA, FACMPE
The Major Types of Accounting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
The Practice Manager’s Responsibility for Accounting and Budgeting . . . . . . . . 248
The Relationship Among the Practice Manager,
the CPA, Auditors, and Potential Lenders . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Principles of Financial Accounting: The Generally
Accepted Accounting Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Cash and Accrual Accounting, and Modified Accrual Accounting . . . . . . . . . . . 253
Methods of Depreciation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Chart of Accounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Flow of Financial Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Internal Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Budgeting for Practice Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Type of Budgets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
The Budget Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
Creating the Statistics Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Creating the Provider Compensation Forecast . . . . . . . . . . . . . . . . . . . . . . . . . . 274
Creating the Expense Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Creating the Revenue Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Creating the Operating Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Creating the Cash Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Creating the Capital Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Zero-Based Budgeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Fixed Versus Flexible Budgeting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Using the Comprehensive Budget as a Management Tool . . . . . . . . . . . . . . . . . 278
Chapter 10 Financial Management and Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .281
Lee Ann H. Webster, MA, CPA, FACMPE
Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Compilations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
In-House Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

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The Accountant’s Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

Bases of Accounting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Financial Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
Statement of Changes in Equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Statement of Cash Flows. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Notes to Financial Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Chapter 11 Practice Benchmarking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .311
Elizabeth W. Woodcock, MBA, FACMPE, CPC
Financial Benchmarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Operational Benchmarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Chapter 12 Health Information Technology for Medical Group Practices . . . . . . . . . . . . .335
Margret Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR, CPHIE, FHIMSS
Scope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Planning for Health Information Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Workflow and Process Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
EHR Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
HIT Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
HIT Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
HIT Optimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
Future Directions in HIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Chapter 13 Office Practice Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .367
Geraldine Amori, PhD, ARM, CPHRM, DFASHRM
The Risk Management Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Office Practice Exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
Personnel Exposures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
Property and Facilities Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Financial and Business Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394

Section III Essential Knowledge for Contemporary Management . . . . . . . . . . . . . . . . . . . . .397

Chapter 14 Legal Issues Associated with Medical Practices
and Business Arrangements in the Healthcare Industry . . . . . . . . . . . . . . .399
Bruce A. Johnson, JD, MPA; Jennifer L. Weinfeld, JD
Legal Issues Related to Medical Practice Organization and Operation . . . . . . . 400
Legal Issues Impacting Medical Practice External Relationships . . . . . . . . . . . . 405
Illustration of Application of Legal Issues to
Accountable Care Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425

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Chapter 15 Labor and Employment Laws Applicable to Physicians’ Practices . . . . . . . . .427

Peter D. Stergios, JD; John M. McKelway, JD; Jennifer Itzkoff, JD
Federal and State Civil Rights Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
Affirmative Action: Federal Contractor Requirements . . . . . . . . . . . . . . . . . . . . 431
Individual Employment Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
Wage and Hour Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Employee Benefits in the Healthcare Industry . . . . . . . . . . . . . . . . . . . . . . . . . . 439
Privacy Issues in the Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440
Safety in the Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
Collective Bargaining and Protected Concerted Activities . . . . . . . . . . . . . . . . . 443
Employment Eligibility Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Conducting an Effective Internal Investigation . . . . . . . . . . . . . . . . . . . . . . . . . 452
Employment Records and Record Keeping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
Chapter 16 Medical Practice Physician Compensation Plans . . . . . . . . . . . . . . . . . . . . . .461
Bruce A. Johnson, JD, MPA
Purpose and Rule of Compensation Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Interplay of Reimbursement and Compensation Structures . . . . . . . . . . . . . . . . 462
Changing Context for Medical Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
Features of Effective Compensation Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
Understanding the Context for Compensation Arrangements . . . . . . . . . . . . . . 464
Basic Plan Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466
Measuring Work and Allocating Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
Noncompensation Issues with Compensation Plan Implications. . . . . . . . . . . . 474
Legal Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
Developing and Changing Compensation Plans. . . . . . . . . . . . . . . . . . . . . . . . . 485
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Chapter 17 Regulatory and Design Issues for an Effective Physician
Practice Compliance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .489
Michael R. Costa, JD, MPH; John M. McKelway, JD; Jennifer Itzkoff, JD
Summary of Fraud and Abuse Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
Identified Physician Compliance Risk Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
The Physician Practice Compliance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
Formal Integration of the Compliance Program . . . . . . . . . . . . . . . . . . . . . . . . . 501
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506
Chapter 18 Implementing and Operating a Physician
Practice Compliance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .507
Lawrence F. Wolper, MBA, FACMPE
The Compliance Plan Within the Context of a Physician Practice . . . . . . . . . . . 508
The Elements of Compliance Plans and Programs . . . . . . . . . . . . . . . . . . . . . . . 515
Managerial Implications of Implementing the Compliance Plan . . . . . . . . . . . . 517
A Planning and Implementation Work Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525

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Chapter 19 Tax-Qualified Retirement Plans and Fringe Benefits. . . . . . . . . . . . . . . . . . . .535

Richard A. Naegele, BA, MA, JD; Kelly Ann VanDenHaute, BS, JD
Tax-Qualified Retirement Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
Cafeteria Plans, Employee Fringe Benefits, and COBRA . . . . . . . . . . . . . . . . . . 544
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554
Chapter 20 Medical Malpractice: An Explanation and Analysis . . . . . . . . . . . . . . . . . . . .567
Chris Morrison, Esq.; Julie M. Brightwell, BSN, JD, CPHRM
Dan Bucsko, MBA, MHA, FACHE, CMPE, CPHRM; Susan Shephard, MSN, CPHRM
Darrell Ranum, JD, CPHRM
The Cause of Action for Medical Malpractices . . . . . . . . . . . . . . . . . . . . . . . . . . 567
The Physician–Patient Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
The Standard of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570
Breaching the Standard of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572
Causation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573
Liability for the Actions of Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573
Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 574
Frivolous Lawsuits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575
The Role of Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 576
The Litigation and Trial Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578
Trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
Appeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582
Consequences of a Medical Malpractice Action . . . . . . . . . . . . . . . . . . . . . . . . . 582
Legislative Attempts to Address Medical Liability . . . . . . . . . . . . . . . . . . . . . . . 584
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585
Chapter 21 Facility Design and Planning for Physician-Based Group Practices . . . . . . . .587
Richard Sprow, AIA; Sonya Dufner, FASID
Christian F. Bormann, AIA, NCARB, LEED AP; Jason Harper, AIA, LEED AP
John Rodenbeck, AIA, NCARB, LEED AP BD+C
The Basics of Architectural Design Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
Beginning the Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
Getting the Project Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593
Sustainable Building and LEED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
Construction Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
Construction Delivery Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
The Quality of the Interior Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
Physical Settings for Group Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
The Programmatic Needs of a Physician-Based Group Practice . . . . . . . . . . . . . 602
Operational Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604
Planning Typologies and the Clinical Environment . . . . . . . . . . . . . . . . . . . . . . 609
Patient Registration: Centralized Versus Decentralized . . . . . . . . . . . . . . . . . . . 610

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Arranging Clinical Spaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610

Shared Support Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
The Clinical Neighborhood Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
Planning for Growth and Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
Codes and Guidelines for Healthcare Facilities . . . . . . . . . . . . . . . . . . . . . . . . . 612
Time, Cost, and Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
Financing Group Practice Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
Planning Your New Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .617

71010_FMxx_FINAL.indd xii 4/30/12 6:24:27 PM


The U.S. healthcare system is in the process of its most
significant change since the creation of Medicare and
Medicaid in 1965. The passage of the Patient Protection
and Affordable Care Act in 2010 initiated a series of
changes in government programs that will change who
has health insurance, how doctors and hospitals are paid,
and how physicians relate to patients, hospitals, and
insurance companies. Simultaneously with the federal
health reform initiatives, commercial health insurance
companies are on a parallel path to create care delivery
programs that are designed to improve quality and reduce
the total cost of care.
Whether change is due to federal legislation or a
response to market forces, the healthcare system of the
future will have a very different structure than what is
observed today. In order to prepare for a transformed
healthcare environment, medical practices and their
leaders need a firm foundation. The second edition of
Physician Practice Management: Essential Operational and
Financial Knowledge was designed to provide the informa-
tion that practice leaders will need now and in the future.
Every critical aspect of practice is addressed in the text by
authors who have attained national recognition for their
expertise and knowledge.
71010_FMxx_FINAL.indd xiii
Foreword
In the midst of the changes underway in the health-
care system, the Medical Group Management Association
(MGMA) and the American College of Medical Practice
Executives (ACMPE) are in their own transformation.
In October 2011, the respective memberships of the
two organizations approved their merger into a new
association effective January 1, 2012. The new associa-
tion, MGMA-ACMPE, will be better positioned to serve
our members and the industry in the rapidly changing
healthcare marketplace. The MGMA-ACMPE vision to
“be the foremost resource for members and their orga-
nizations in creating and improving systems that com-
plement the delivery of affordable, quality patient care”
shows our commitment to the needs of medical practices
and their leaders.
The 21 chapters of the second edition of Physician
Practice Management: Essential Operational and Financial
Knowledge address the spectrum of management issues
facing medical practices. The text is divided into three
sections to concentrate similar topics for the reader’s
convenience. Each of these sections, Practice Operations
and Functions, Monitoring and Controlling Physician
Organizations, and Essential Knowledge for Contemporary
Management, could stand alone as a definitive text; in
xiii
4/30/12 6:24:28 PM
 xiv | Foreword
combination, they make this text the most comprehensive
source of practice management information available in
a single document.
Section I, Practice Operations and Functions, pro-
vides a broad overview of health issues including the
evolution of medicine and how healthcare is delivered in
other countries. The section continues with chapters that
address general practice operations, the organization of
medical groups, physician leadership, nursing leadership,
human resources management, and marketing. Six of the
chapters in this section were in the First Edition and have
received extensive updates, including the differences in
the manner in which malpractice lawsuits are handled and
the impact of these lawsuits in the United States. A new
Chapter 7, Public Health and Private Physician Medical
Practice Preparedness: Can We Be Medically Prepared for
the Next Disaster?, replaces the chapter on bioterrorism
in the first edition with information that discusses how a
medical practice can prepare for and minimize the impact
of natural or human-caused disasters.
Section II, Monitoring and Controlling Physician
Organizations, addresses the controlling and management
systems within the practice. This section has chapters that
address governance, accounting, finance, benchmark-
ing techniques, electronic health records, management
information systems, and risk management that update
the content of the first edition. It begins with a new chap-
ter, Physician Practice: Organization, Management, and
Operation, which introduces the section and provides
a summary of information on practice governance and
organizational structure.
The last section, Essential Knowledge for
Contemporary Management, has six chapters that update
the content of the First Edition. These chapters cover the
laws and federal regulations that affect internal operations
and external relationships. They also address how com-
pensation plans can incentivize provider productivity and
how facility design affects patient care and throughput.
Two new chapters focus on the information that health-
care leaders need to structure physician employment
contracts that comply with federal regulations.
Just as this text is the definitive reference for a medi-
cal practice or senior hospital executive, it also is the
71010_FMxx_FINAL.indd xiv
ideal reference for administrators seeking ACMPE cer-
tification or Fellowship. The certification test process
is designed to verify and validate expertise and experi-
ence in medical practice management; administrators
who pass the ACMPE certification examinations are
recognized as having the unique knowledge and skill
set for medical practice management. The extensive
depth of content in the second edition of Physician
Practice Management: Essential Operational and Financial
Knowledge makes this text the ideal study guide for the
ACMPE examinations because the chapters in this book
cover the entire scope of the body of knowledge for
medical practice management.
The chapter authors represent a cross-section of
the most knowledgeable authorities in their fields. The
authors come from academia, healthcare organizations,
law firms, associations, architectural firms, and consult-
ing organizations and bring a level of expertise that is
unmatched in any other health management publication.
The authors’ academic and professional credentials are
exemplary, with many holding dual professional degrees.
Additionally, most of the authors have attained the high-
est level of certification and recognition in their respec-
tive fields. Among the medical practice executives who
contributed to this text, nine are either Certified Medical
Practice Executives or Fellows in the American College
of Medical Practice Executives (ACMPE). Attaining
Fellowship in the ACMPE is the highest credential in
medical practice management.
The first edition of Physician Practice Management:
Essential Operational and Financial Knowledge was pub-
lished in 2005 and was quickly recognized as the authori-
tative text describing medical practice management. This
second edition adds new information that keeps the pub-
lication current so it can continue to meet the demanding
information needs of medical practice leaders. This text
should be included on the bookshelf of every medical
practice executive.
Susan Turney, MD, MS, FACP, FACMPE
President and Chief Executive Officer
MGMA-ACMPE
Englewood, Colorado
4/30/12 6:24:28 PM

When the outlining of this book began, all authors, coau-
thors, and editors realized that we were entering a time of
significant change in the healthcare industry. As stated in
the foreword, it did not matter whether the change was
being influenced by legislation or by other exogenous
factors. Rapid and, at times, contentious change was
occurring. The challenge was how to write and produce
a text that would both be able to address these possible
changes and be accurate and educational. The writing of
the manuscripts was paced in such a way that the authors
would have enough time to research and absorb possible
changes, and to determine the degree to which they could
or would affect their specific topical areas. Some authors’
topics were likely to be dramatically affected, and others
to a lesser degree. In retrospect it appears that the longer
process time for the book has paid off.
There are 21 chapters in the second edition of this
text, all written by authors with outstanding reputations
in each of their respective areas of expertise. Most have
terminal degrees in their fields, and nine are Fellows in
the American College of Medical Practice Executives.
There are new authors as well, such as Sheila Richmeier
who wrote an outstanding chapter on nursing manage-
ment and the changes that are, and will be, occurring
in that area, and Neill Piland who coordinated, with his
71010_FMxx_FINAL.indd xv
Acknowledgments
coauthors, a very robust chapter on disaster prepared-
ness. The lead author of that chapter, Denise O’Farrell,
has achieved excellence in threading many subtopics
together into a critical chapter, and doing so in such a
highly professional manner, while at the same time per-
sonally facing other life challenges. Other new authors
are Richard Naegele and Kelly Ann VanDenHaute, who
took a topic of quite some detail, tax-qualified retirement
plans and fringe benefits, and made it easily understood
and very much on point. Perhaps the most likely area to
absorb major change now and in the future is information
systems, and Margret Amatayakul wrote an exemplary
chapter on this topic. Changes affecting this area can be
encompassed in entire texts, but Margret has covered
the subject well, and logically, in just one chapter. Dan
Buscko and his coauthors also wrote an excellent chapter
on medical malpractice, an area that may change in the
future.
Special thanks to Bruce Johnson, who, with an
extremely busy schedule, was able to complete two chap-
ters, one with colleague Jennifer Weinfeld and one by
himself. Peter Stergios and colleagues wrote a chapter on
labor and employment law that is very interesting, and
is one of those areas that is likely to sustain substantial
change in the future.
xv
4/30/12 6:24:28 PM
 xvi | Acknowledgments
Thanks to each of the authors who have published
in previous editions of this book for their unhesitating
willingness to, once again, go through the process. The
accounting and budgeting chapter written by Steven
Andes and Dave Gans, the chapter on financial manage-
ment and reporting by Lee Ann Webster, and the one on
practice benchmarking written by Elizabeth Woodcock,
all updated, integrate with each other as if they were
meant to be a small book on these interlocking topics.
Continued thanks to Geraldine Amori for her chapter
on risk management, and Mike Kelley and colleagues
for their chapter exploring practice organization and
finance.
Another area that is likely to continue to experience
significant change, as MDs coalesce into large and super-
large groups and hospitals continue to acquire practices,
is facility design for large practices. The chapter on facility
design, written by Richard Sprow and colleagues, is exem-
plary in exploring the architectural and design implica-
tions of the medical office of the future. As Medicare,
Medicaid, and commercial insurers increase the intensity
of fraud and abuse auditing, and Medicare in particular
continues to recoup large sums of money for noncom-
pliance, the chapter composed by Michael Costa and his
colleagues is a must-read.
The remaining authors who are to be acknowledged
are Grant Savage and his colleagues, who, once again,
have raised the bar on their comparative analysis of, now,
12 countries. They also have expanded the analysis of
these countries to include the manner in which malprac-
tice lawsuits are adjudicated, whether there are limita-
tions on malpractice monetary awards, and, in the case
of the United States, how much is spent on malpractice
awards. Stephen Wagner has written an excellent chapter
on the organization and operations of medical groups. As
the number of large medical groups continues to increase,
whether they are independent or part of a system, physi-
cian leadership and “team” physician and lay leadership
become more important.
In the 1990s, when large-scale physician acquisition
by hospitals occurred, some believed that not enough
time was expended in on-boarding physicians who had
long practiced in small groups, and little time and atten-
tion were given by many organizations to accommodate
the abrupt change from private practice to employed
physician. They were now legally employees of hospi-
tals, but the result, in retrospect, did not appear to be
satisfactory or productive. Dr. Gary Kaplan, the chair-
man and CEO of Virginia Mason Health System, a very
respected integrated system, has shared his experience
about physician leadership in medical group practice.
71010_FMxx_FINAL.indd xvi
The challenges in building a team approach to leadership
and management, and the positive alignment of hospitals
with physicians, is an addition to this book that is well
worth reading. An award-winning book, Transforming
Health Care: Virginia Mason Medical Center’s Pursuit of
the Perfect Patient Experience, by Charles Kenney, also is
worth reading. It takes the reader through the ups and
downs of creating an aligned system that works, the end
product of which is a positive patient experience and keen
attention to clinical outcomes.
Many hospitals currently may be making “over-
sights” similar to those in the 1990s, and in addition to
the previously mentioned topic of physician leadership,
the area of marketing also continues to be overlooked.
Roberta Clarke, a professor, author, and leader in mar-
keting healthcare, writes a comprehensive chapter that
addresses good marketing in general, but how marketing
is even more important in a changing industry. Branding
an enlarging health system as a “system” is important, but
creating a public identity for a large physician network
or group also is important.
In 1910 Abraham Flexner wrote a book on medical
education in the United States and Canada (The Flexner
Report); to this day, many of the suggestions he made con-
tinue to influence hospitals and physicians. Many aspects
of the book, sponsored by the Carnegie Foundation, also
remain controversial. It stated, among many things, that
the hospital was the doctor’s workshop (much less so now
with the emergence of very large independent groups with
satellite offices that provide a wide range of services).
Flexner’s statement is likely to be the case in the future,
regardless of the size and geographic reach of a system.
Therefore, subordinating the identity of a large physi-
cian group or network that is owned by a health system
may be underutilizing the marketing and public relations
“capital” of the physicians. Dr. Clark provides a compel-
ling argument for the importance of marketing in today’s
changing environment. It is perhaps even more important
now than historically, because as systems expand in size,
the consumer has greater difficulty in differentiating the
centers of excellence among these organizations because
without astute marketing they may sound like they all
are excellent in all things . . . and logic suggests that this
cannot be the case.
The last area that has evolved quickly in response to
the speed of change in the industry is human resources
management, and Michael O’Connell has produced a
chapter that considers the new pressures on this criti-
cal function in a rapidly changing setting; as in the
first edition, he does so in an easy-reading, yet detailed
manner.
4/30/12 6:24:28 PM
 Acknowledgments | xvii

In summary, the authors of this text all are highly hope that this text becomes one that is widely read for
skilled, trained, and respected in their respective fields. the knowledge and wisdom that it contains, and the con-
Many have multiple academic degrees. Yet, in spite of temporary healthcare issues that it addresses.
the fact that they all are extremely busy, they took the
time and effort to research, to speculate on the impact
of changes in the industry, and to envision the impact of
those changes on their own areas of specialization.
I thank all authors, coauthors, and editors for self- Lawrence F. Wolper
lessly taking the time to work on this project. It is my Managing Editor/Author

71010_FMxx_FINAL.indd xvii 4/30/12 6:24:28 PM

71010_FMxx_FINAL.indd xviii 4/30/12 6:24:28 PM

Lawrence F. Wolper, MBA, FACMPE, is president of L.
Wolper, Inc., in Morristown, New Jersey. The firm is a full-
service consulting organization specializing in all aspects
of physician group practice, hospital alignment, revenue
cycle assessment, and managed care. In addition, L.
Wolper, Inc., has extensive experience in managing large
physician group practices and ambulatory surgery centers
in order to assist them in achieving strategic growth goals
and to augment operational and financial efficiencies.
Mr. Wolper has more than 25 years of consulting
and senior executive experience, and has been the advi-
sor to, or managed, major group practices, faculty prac-
tice plans, ambulatory surgery centers, and integrated
networks. Prior to founding his firm in 1987, he was
a partner in KPMG, International, LLP, with New York
area and national responsibility for physician practice
and ambulatory care consulting. At that time, he was
involved in the development of large group practices,
faculty practice plans, and provider networks. Prior to
his partnership in KPMG, he was a consulting partner
with Ingram, Weitzman, Mertens & Co., a large regional
healthcare accounting and consulting firm.
He has published more than 35 professional jour-
nal articles and 8 texts on a variety of subjects that are
71010_FMxx_FINAL.indd xix
About the Managing
Editor/Author
germane to physician and faculty practice, and to health-
care administration. His book Health Care Administration:
Principles, Practices, Structure, and Delivery, Second Edition,
won a prestigious national award as one of the top 250
texts in the health sciences industry. The text was recently
released in its fifth edition, and remains one of the leading
texts in the industry.
Mr. Wolper received an MBA in healthcare
administration from Bernard M. Baruch College/Ricklin
School of Business–Mount Sinai School of Medicine, and
a BA in advertising/marketing from Hofstra University.
He was a Robert Wood Johnson Foundation Fellow in
HMO management at the Wharton School, University
of Pennsylvania, and an Association of University
Programs in Hospital Administration (AUPHA)
Fellow studying the British National Health System at
the Kings Fund College of Hospital Management in
London, England.
He is a Fellow in the American College of Medical
Practice Executives, and was an Associate Adjunct
Professor in the Executive MPH Program at Columbia
University, teaching a course on managed care and orga-
nized delivery systems.
xix
4/30/12 6:24:29 PM
71010_FMxx_FINAL.indd xx 4/30/12 6:24:29 PM
 Contributors

Margret Amatayakul, MBA, RHIA, CHPS, CPHIT, Mohamed Bouras, MS

CPEHR, CPHIE, FHIMSS University of Missouri-Columbia
President Columbia, Missouri
Margret\A Consulting, LLC
Schaumburg, Illinois
Julie M. Brightwell, BSN, JD, CPHRM
Geraldine Amori, PhD, ARM, CPHRM, DFASHRM Director, Patient Safety Programs
Vice President, Education Center The Doctors Company
Risk Management and Patient Safety Institute Powell, Ohio
Shelburne, Vermont
Dan Bucsko, MBA, MHA, FACHE, CMPE, CPHRM
Stephen M. Andes, PhD, CPA
Vice President
Research Assistant Professor, Division of Health Policy
The Doctors Company
and Administration
Vacaville, California
University of Illinois School Public Health
Niles, Illinois
Roberta N. Clarke, MBA, DBA
Keri D. Black, PhD, CFNP Associate Professor, Health Care
Assistant Professor and Clinical Educator Management Program
University of New Mexico College of Nursing Boston University
Albuquerque, New Mexico Weston, Massachusetts
Christian F. Bormann, AIA, NCARB, LEED AP
Architect Michael R. Costa, JD, MPH
Perkins & Will Attorney, Greenberg Trauig, LLP
New York, New York Boston, Massachusetts

xxi

71010_FMxx_FINAL.indd xxi 4/30/12 6:24:29 PM

 xxii | Contributors

Sonya Dufner, FASID Richard A. Naegele, BA, MA, JD

Director of Workplace Wickens, Herzer, Panza, Cook & Batista Co.
Perkins & Will Avon, Ohio
New York, New York
Richard D. Norwood, CPA, FHMA, MBA
Steven Falcone, MD, MBA Finance Director, Faculty Practice
Chief Operating Officer, UHealth Faculty Practice University of Miami Miller School of Medicine
University of Miami Miller School of Medicine Miami, Florida
Miami, Florida
Michael A. O’Connell, MHA, FACHE, FACMPE
David N. Gans, MSHA, FACMPE Vice President of Clinical Services
Vice President, Innovation and Research Marymount and Southpoint Hospitals
Medical Group Management Association Solon, Ohio
Englewood, Colorado
Denise O’Farrell, MPH
Jason Harper, AIA, LEED AP Healthcare Liaison
Associate Principal Southeastern District Health Department
Perkins & Will Pocatello, Idaho
New York, New York
Annette Phillipp, PhD, MPH
Jennifer Itzkoff, JD Research Assistant Professor, Institute of Rural Health
Associate Idaho State University
McCarter & English Meridian, Idaho
Boston, Massachusetts
Neill F. Piland, PhD
Bruce A. Johnson, JD, MPA Research Professor, Director, Institute of Rural Health
Shareholder Idaho State University
Polsinelli Shughart, PC Pocatello, Idaho
Denver, Colorado
Darrell Ranum, JD, CPHRM
Gary S. Kaplan, MD, FACMPE, FACP Regional Vice President, Patient Safety
Chairman and CEO The Doctors Company
Virginia Mason Health System Columbus, Ohio
Seattle, Washington
Leo van der Reis, MD
Michael J. Kelley, MBA, CMPE Director
Vice Chairman, University of Miami Medical Group Quincy Foundation for Medical Research
University of Miami Miller School of Medicine University of Alabama at Birmingham
Miami, Florida San Francisco, California

John M. McKelway, JD Sheila Richmeier, MS, RN, FACMPE

Partner Owner and Consultant
McCarter & English Remedy Healthcare Consulting, LLC
Boston, Massachusetts Kansas City, Montana

Chris Morrison, Esq John Rodenbeck, AIA, NCARB, LEED AP BD+C

Attorney Architect
Adventist Health System Perkins & Will
Winter Park, Florida New York, New York

71010_FMxx_FINAL.indd xxii 4/30/12 6:24:29 PM

 Contributors | xxiii

Grant T. Savage, PhD, MBA, BA Peter D. Stergios, JD

Professor of Management Partner
University of Alabama at Birmingham McCarter & English
Birmingham, Alabama New York, New York

Kelly Ann VanDenHaute, BS, JD

Stephen G. Schwartz, MD, MBA
Associate Professor of Clinical Ophthalmology
University of Miami Miller School of Medicine
Miami, Florida
Susan Shephard, MSN, CPHRM
Director, Patient Safety Education
The Doctors Company
Niceville, Florida
Howard L. Smith, PhD
Professor, Department of Management
College of Business and Economics,
Boise State University
Boise, Idaho
Attorney
Wickens, Herzer, Panza, Cook & Batista Co.
Avon, Ohio
Stephen L. Wagner, PhD, FACMPE
Vice President Medical Education and Research
Carolinas Healthcare System
Charlotte, North Carolina
Lee Ann H. Webster, MA, CPA, FACMPE
Pathology Associates of Alabama, PC
Birmingham, Alabama
Jennifer L. Weinfeld, JD
Counsel
Polsinelli Shughart, PC
Denver, Colorado

Richard Sprow, AIA Elizabeth W. Woodcock, MBA, FACMPE, CPC

Architect Principal
Perkins & Will Woodcock & Associates
New York, New York Atlanta, Georgia

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71010_FMxx_FINAL.indd xxiv 4/30/12 6:24:29 PM

Chapter 1
Mohamed Bouras, MS, is a graduate student in health
administration at the University of Missouri-Columbia.
Mr. Bouras holds a Master of Science degree in agri-
culture and resource economics from the University of
Connecticut. His research interests focus on medical
groups’ productivity, health information technology, and
management of healthcare systems.
Leo van der Reis, MD, graduated with honors from the
University of Chicago in 1954. His postgraduate training
was in internal medicine and gastroenterology. In addition
to the clinical practice of medicine, Dr. van der Reis has done
extensive research and written on issues of healthcare policy.
Dr. van der Reis is director of the Quincy Foundation for
Medical Research–Charitable Trust and an adjunct professor
in healthcare management and clinical professor of com-
munity and rural medicine at The University of Alabama.
Grant T. Savage, PhD, MBA, BA, is professor of management
in the School of Business at the University of Alabama at
Birmingham and holds joint appointments in the School
of Medicine and School of Public Health. He codirects the
Healthcare Leadership Academy for the UAB academic
medical center, and is a founding series editor for Advances
in Health Care Management, published by Emerald Group
71010_FMxx_FINAL.indd xxv
Contributor
Biographies
Publishing. Dr. Savage has written extensively on health-
care management, communication, and negotiation issues,
focusing primarily on stakeholder analysis and collabora-
tion. He has coauthored six award-winning papers, and
currently is engaged in healthcare research on employee
and patient safety and on comparative international health
management, as well as multisector research on stake-
holder collaboration and economic development.
Chapter 2
Stephen L. Wagner, PhD, FACMPE, lives in Charlotte, North
Carolina, and serves as the Vice President of Business
Curriculum and Resident Development for the Carolinas
Healthcare System, the third largest public healthcare sys-
tem in the United States. He has been active in the field
of healthcare as an executive, teacher, and researcher for
more than 35 years.
Dr. Wagner currently teaches healthcare management
in the Seton Hall University in the Master’s of Health
Administration program and serves as the Executive
in Residence. He also teaches at University of North
Carolina at Charlotte. Dr. Wagner holds a master’s degree
in healthcare fiscal management from The University of
Wisconsin-Madison School of Business and a PhD from the
University of Louisville College of Business in healthcare
xxv
4/30/12 6:24:29 PM
 xxvi | Contributor Biographies
public policy analysis. Dr. Wagner’s principal areas of
emphasis are in medical practice administration, medi-
cal economics, community health, international medi-
cine, new healthcare and educational technologies, and
healthcare policy. His research has focused on outcome
measurement for cardiovascular services, cardiovascular
health, the use of Internet-based tools for patient self-
management, and the development of healthcare systems
in underserved communities, both domestic and interna-
tional. Dr. Wagner has been involved in establishing med-
ical practices and community services in St. Petersburg,
Russia, and continues to work on healthcare service and
cardiovascular issues in Charlotte.
Other publications include a book titled Organizational
Governance and Group Dynamics, published by the MGMA
as part of its American College of Medical Practice Executive
Body of Knowledge Series (2006, revised 2008). More
recently, Dr Wagner served as the coinvestigator of a study,
“Effect of a Web-Based Self-Management Intervention on
Patient Activation: A Randomized Controlled Trial.” The
study was presented at the HIMSS11 Annual Conference
and an article of the same name is in press at the Journal
of Medical Internet Research.
Dr. Wagner is a Fellow in the American College of
Medical Practice Executives and has served as its exami-
nation committee chair.
Chapter 3
Gary S. Kaplan, MD, FACMPE, FACP, has served as chair-
man and CEO of the Virginia Mason Health System since
2000. He is a practicing internal medicine physician at
Virginia Mason.
During Dr. Kaplan’s tenure as chairman and CEO,
Virginia Mason has received significant national and
international recognition for its efforts to transform
healthcare. Recent recognitions include:
■ Virginia Mason was named the “Top Hospital of
the Decade” for patient safety and quality by The
Leapfrog Group, a distinction shared with only
one other hospital.
■ Virginia Mason received the highest overall score of
any reporting hospital in the Pacific Northwest in
the 2010 and 2011 surveys by The Leapfrog Group.
In 2010, Virginia Mason also had the best safety
ratings in Washington state for high-risk proce-
dures, as well as the best overall patient safety rat-
ings among all reporting hospitals.
■ Virginia Mason is one of only 238 hospitals out of
6,000 nationwide to receive the 2011 HealthGrades
Patient Safety Excellence Award.
71010_FMxx_FINAL.indd xxvi
■ Virginia Mason was one of five hospitals honored
with the 2011 American Hospital Association-
McKesson Quest for Quality Prize, presented annu-
ally to honor leadership and innovation in quality
improvement and safety.
■ Virginia Mason was named a 2011 Distinguished
Hospital for Clinical Excellence by HealthGrades,
placing Virginia Mason among the top 5% of hos-
pitals nationwide—the fourth time Virginia Mason
had earned this honor.
Virginia Mason is considered to be the national leader
in deploying the Toyota Production System to health-
care management—reducing the high costs of healthcare
while improving quality, safety, and efficiency to deliver
better, faster, and more affordable care.
In addition to caring for patients and serving as
chairman and CEO, Dr. Kaplan is a clinical professor at
the University of Washington and has been recognized
for his service and contribution to many regional and
national boards, including the Institute for Healthcare
Improvement, the Medical Group Management
Association, the National Patient Safety Foundation, the
Greater Seattle Chamber of Commerce, the Washington
Healthcare Forum, the Seattle Foundation, and Special
Olympics of Washington.
Dr. Kaplan is a founding member of Health CEOs for
Health Reform and has been recognized nationally for his
healthcare leadership.
■ Modern Healthcare ranked Dr. Kaplan thirty-third
in its 2011 listing of the 100 Most Influential
People in Healthcare.
■ Modern Physician and Modern Healthcare ranked
Dr. Kaplan twelfth in the 2011 listing of the 50
Most Influential Physician Executives.
■ In 2011, Becker’s Hospital Review listed Dr. Kaplan
as one of the 13 Most Influential Patient Safety
Advocates in the United States, and named him as
one of 291 U.S. Health and Hospital Leaders to Know.
Some of Dr. Kaplan’s other awards and distinctions
include:
■ The 2009 John M. Eisenberg Award from the
National Quality Forum and The Joint Commission
for Individual Achievement at the national level for
his outstanding work and commitment to patient
safety and quality.
■ The Harry J. Harwick Lifetime Achievement Award
for outstanding contributions to healthcare from the
Medical Group Management Association and the
American College of Medical Practice Executives.
4/30/12 6:24:30 PM

Dr. Kaplan received his medical degree from the
University of Michigan and is board certified in inter-
nal medicine. He is a Fellow of the American College
of Physicians (FACP), the American College of Medical
Practice Executives (FACMPE), and the American College
of Physician Executives (FACPE).
Chapter 4
Sheila Richmeier, MS, RN, FACMPE, has established sig-
nificant expertise in medical practice redesign with over
20 years of experience in healthcare. Key to her quali-
fications and success is her ability to objectively ana-
lyze situations and determine potential opportunities.
Throughout her career, Sheila has managed clinical staff;
provided oversight for business, financial, and clinical
aspects of a medical office; and provided key insights in
various consulting projects. Drawing upon diverse hos-
pital, home health, and primary and specialty care expe-
riences, Sheila provides practical efficiency solutions to
medical offices. As a facilitator, Sheila has worked with
primary care practices throughout the country to assist
with the transformation to patient-centered medical
homes. This work was a culmination of all her experi-
ences and expertise in medical practice management and
clinical operations. Successes include improvement in
quality and clinical outcome analysis, and physician, staff,
and patient satisfaction, along with improved efficiencies
in financial and operational areas. Recently Sheila opened
her own business, Remedy Healthcare Consulting, and
provides services to both primary and specialist practices
throughout the country.
Sheila is a registered nurse and a fellow in the American
College of Medical Practice Executives with a master’s
degree in nursing administration from the University of
Kansas. Sheila speaks on the national stage and has pub-
lished numerous books, including Leading Your Clinical
Team: A Comprehensive Guide to Optimizing Productivity
and Quality, published by MGMA in July 2009, and The
New Healthcare Supervisor’s Guide: The Secrets to Success,
published by MGMA in March 2010. She also authored
Fast Facts: Medical Office Nursing, published by Springer
Publishing in June 2010.
Chapter 5
Michael A. O’Connell, MHA, FACHE, FACMPE, is an experi-
enced senior healthcare leader working at two of Cleveland
Clinic’s regional hospitals and medical groups in Cleveland,
Ohio. He has been responsible for operations of medi-
cal practices, hospitals, and physician services including
recruitment, retention, and development of employees and
71010_FMxx_FINAL.indd xxvii
Contributor Biographies | xxvii
physicians. He has worked extensively to engage teams to
accomplish great results in the areas of patient experience,
employee engagement, operations, and process improve-
ments. He has served on the local boards of the American
College of Healthcare Executives (ACHE) and Medical Group
Management Association (MGMA) and is a fellow in the
ACHE and American College of Medical Practice Executives
(ACMPE). He has made numerous national presentations
and spoken on diverse topics such as human resources,
healthcare operations, sustainability, and corporate compli-
ance. He has authored a book for the MGMA on the body
of knowledge review titled Human Resource Management.
He also has worked extensively to mentor medical practice
leaders to pursue their board certification in the ACMPE
and presently serves as the ACMPE’s Advancement Chair.
He has a Bachelor of Science from University of Illinois,
Urbana, and a Master of Health Administration from Saint
Louis University, Saint Louis, Missouri.
Chapter 6
Roberta N. Clarke, MBA, DBA, is associate professor in
Boston University’s Health Care Management Program.
She is vice chairman of the Board of the Academy for
Educational Development, one of the largest human
development agencies, and also a member of the Board
of Trustees of the New England Organ Bank. Professor
Clarke is the 1995 recipient of the American Marketing
Association’s prestigious Philip Kotler Award for
Excellence in Health Care Marketing. She is former
president of the Society for Health Care Planning and
Marketing, at that time a national professional society
of 3,500 members affiliated with the American Hospital
Association. Dr. Clarke won the Health Care Marketer of
the Year Award from the American College of Health Care
Marketing in 1985, the first year it was awarded. She has
been teaching healthcare marketing courses at Boston
University’s Health Care Management Program since
January 1974. Professor Clarke has served on the edito-
rial review board of the Journal of Health Care Marketing as
well as other healthcare publications. With Philip Kotler,
she coauthored Marketing for Health Care Organizations,
considered to be the first and leading text in the field of
healthcare marketing. She was the cofounder of Great
Moves!, a pediatric weight management program affili-
ated with The Physicians of Children’s Hospital Boston.
She currently is the president and cofounder of Advance
Medical, an expert second medical opinion service serv-
ing over 1.4 million people in the United States. Professor
Clarke received her master’s and doctorate from the
Harvard Graduate School of Business Administration.
4/30/12 6:24:30 PM
 xxviii | Contributor Biographies
Chapter 7
Keri D. Black, PhD, CFNP, is an associate professor at
the University of New Mexico College of Nursing and a
family nurse practitioner in urgent care.
David N. Gans, MSHA, FACMPE, is the vice president
of Innovation and Research at the Medical Group
Management Association (MGMA). Mr. Gans administers
research and development at the MGMA and its research
affiliate, the MGMA Center for Research. In addition to
his management responsibilities, he is an educational
speaker, authors a monthly column in MGMA’s journal,
and serves as the association’s staff resource on all areas
of medical group practice management. The current
research focus addresses the four issues of importance
to medical practice executives: patient safety and qual-
ity; administrative simplification, cost efficiency, and the
dissemination of best practices; information technology;
and preparing for healthcare reform and a transformed
health delivery system.
Mr. Gans received his Bachelor of Arts degree in gov-
ernment from the University of Notre Dame, a Master
of Science degree in education from the University of
Southern California, and a Master of Science degree in
health administration from the University of Colorado.
Mr. Gans is retired from the U.S. Army Medical Service
Corps in the grade of Colonel, U.S. Army Reserve. He is a
Certified Medical Practice Executive and a Fellow in the
American College of Medical Practice Executives.
Denise O’Farrell, MPH, has a master’s degree in public health
from Idaho State University. Ms. O’Farrell is employed
with the Southeastern District Health Department in the
Public Health Preparedness Program. She is the emergency
preparedness healthcare liaison, working with eight hos-
pitals, community health centers, and emergency medical
services agencies developing emergency preparedness and
response plans in southeastern Idaho for the Assistant
Secretary for Preparedness and Response’s Hospital
Preparedness Program. Ms. O’Farrell is also the coordina-
tor for the Southeast Idaho Medical Reserve Corps unit.
Annette Phillipp, PhD, MPH, is a research assistant pro-
fessor for the Institute of Rural Health at Idaho State
University. Her professional and educational background
is in health services research, health promotion, disease
prevention, community health education, consumer
health information, and outcomes research. Dr. Phillipp
has significant research experience in emergency pre-
paredness, specifically in the areas of health services and
simulation-based training. Additional areas of research
include the economics of injuries, human patient simula-
tion integration within clinical education, and adolescent
71010_FMxx_FINAL.indd xxviii
and childhood obesity. Dr. Phillipp is a member of several
professional organizations and currently serves on the
board of the Idaho Rural Health Association. Dr. Phillipp
has presented research findings at national, state, and
local meetings regarding emergency preparedness and
curriculum development, community-based hospital dis-
charge planning for persons with disabilities, and various
health and wellness topics. Her publications have focused
on emergency preparedness for office practices as well as
wellness, health promotion and disease prevention inter-
ventions, services, and outcomes.
Neill F. Piland, PhD, is research professor and director
at the Idaho State University (ISU) Institute of Rural
Health. Prior to coming to ISU in 2002 he was director
of the Medical Group Management Association (MGMA)
Center for Research for 6 years, founding director of New
Mexico’s Lovelace Institute for Health and Population
Research for 13 years, and assistant director of the Health
Services Research Program at the Stanford Research
Institute (now SRI International). A health economist and
health services researcher, he received his doctorate in
health services administration from UCLA and also holds
master’s degrees in public health and economics from
UCLA and UC Davis, respectively. He has been principal
investigator for more than 40 major research and demon-
stration projects. These include evaluation of the quality
of care in Arizona’s Medicaid managed care experiment
(AHCCCS), the New Mexico project for the Community
Intervention Trial for Smoking Cessation (COMMIT)
community trial, and a national study of physician pro-
filing. He recently completed a large Assistant Secretary
of Preparedness and Response (ASPR)/Health Resources
and Services Administration (HRSA) funded program
to prepare Idaho’s healthcare workforce for bioterrorism
and disaster events through the application of innovative
distance learning delivery systems. He has authored or
coauthored more than 90 journal articles, four books, and
numerous book chapters on healthcare delivery, health
promotion, and healthcare financing.
Howard L. Smith, PhD, is professor in the Department
of Management, former vice president (2007–2011) for
University Advancement, and past dean (2006–2007)
of the College of Business and Economics at Boise State
University. He formerly served as dean (1994–2004)
at the Anderson School of Management and School
of Public Administration, University of New Mexico,
Director of the Program for Creative Enterprise and the
Creative Enterprise Endowed Chair (2004–2006). From
1990 to 1994 Dr. Smith served as associate dean at the
Anderson Schools. He has published over 230 articles on
4/30/12 6:24:30 PM

health services, organization theory/behavior, and strate-
gic management topics in journals such as the Academy of
Management Journal, Health Services Research, Health Care
Management Review, and New England Journal of Medicine.
He has published six books on prospective payment, staff
development, hospital competition, financial manage-
ment, strategic nursing management, and reinventing
medical practice, and published three books on nature
literature: In the Company of Wild Bears: A Celebration of
Backcountry Grizzlies and Black Bears (Lyons Press, 2006),
Mountain Harmonies: Walking the Western Wildernesses
(UNM Press, 2004), and The Last Best Adventure
(CreateSpace, 2011). He also published Taking Back the
Tower: Simple Solutions for Saving Higher Education with
Greenwood Press/Praeger Publishers (2009).
Chapter 8
Steven Falcone, MD, MBA, is the chief operating officer,
UHealth Faculty Practice, and associate vice president
for medical affairs and associate executive dean for prac-
tice development, University of Miami Miller School of
Medicine. He is also professor of radiology, neurologi-
cal surgery, and ophthalmology, University of Miami
Miller School of Medicine. Previously he served as the
medical director of radiology services in the Department
of Radiology and vice chair of the University of Miami
Medical Group. Dr. Falcone is a delegate for the American
Society of Neuroradiology to the House of Delegates of
the American Medical Association. He obtained his MD
and MBA degrees from the University of Miami and is
board certified by the American Board of Radiology with
added qualification in neuroradiology.
Michael J. Kelley, MBA, CMPE, is the vice chairman of the
University of Miami Medical Group, the faculty practice
plan of the University of Miami Miller School of Medicine,
having previously acted as the director of satellite opera-
tions and ambulatory surgery for the Bascom Palmer Eye
Institute. Mr. Kelley began his healthcare career in 1980
and has participated as a lecturer in numerous profes-
sional educational programs, with a focus on financial
management. He has served on the executive committee
as president of the Ophthalmology Assembly, Medical
Group Management Association, and has chaired the
American Academy of Ophthalmology’s committee
guiding the development of administrator skill levels.
He received a BS in biology as a Faculty Scholar and an
MBA with an emphasis in marketing and management
at Florida Atlantic University. Mr. Kelley is active as a
member of the Medical Reserve Corps, and has led first
response teams for Hurricanes Katrina and Rita, as well
71010_FMxx_FINAL.indd xxix
Contributor Biographies | xxix
as acting as one of the chief administrative officers at the
University of Miami Field Hospital in Haiti, following the
earthquake of 2010.
Richard D. Norwood, CPA, FHMA, MBA, is the finance
director of the Faculty Practice for the University of
Miami Miller School of Medicine, where he developed
and implemented several financial improvements such
as incentive plans and revenue cycle improvement ini-
tiatives. Previously, he served as chief financial officer of
clinics and hospitals at the University of Texas Medical
Branch in Galveston, Texas, where he worked closely to
align hospital and faculty interests in an academic set-
ting. Mr. Norwood has acted as a consultant providing
management and financial oversight at the Schools of
Nursing, Allied Health Sciences, and Graduate School.
His 35-year career in health began as a Medicare auditor
and has included Catholic Health Care as the controller,
as well as various financial leadership positions and con-
sulting engagements in hospitals and HMOs providing
interim management, implementation of hospital pro-
ductivity management, and implementation of financial
reporting for providers assuming risk.
Stephen G. Schwartz, MD, MBA, is associate professor of
clinical ophthalmology at University of Miami Miller School
of Medicine, and medical director of Bascom Palmer Eye
Institute at Naples. He is the president of the Florida Society
of Ophthalmology. Dr. Schwartz is board certified by the
American Board of Ophthalmology and is a practicing vit-
reoretinal surgeon. He received a BS with honors in bio-
logical sciences at Cornell University, an MD at New York
University School of Medicine, and an MBA at Northwestern
University’s Kellogg School of Management.
Chapter 9
Steven M. Andes, PhD, CPA, is a research assistant profes-
sor in the Division of Health Policy and Administration
at the University of Illinois School of Public Health.
He also teaches accounting, auditing, and healthcare
policy analysis in the School of Continuing Studies at
Northwestern University. He has also taught organiza-
tional design and behavior. Dr. Andes was the manager
of the Policy Evaluation Group of the American Hospital
Association and the manager of applied research of the
American Osteopathic Association, in addition to his
academic positions. He is a fellow of the Institute of
Medicine of Chicago and is a member of the Illinois CPA
Society, where he is a member of the Nonprofit Committee
and chaired the Health Care Committee. His research,
teaching, and consulting interests include practice effi-
ciency, cost-benefit analysis, and the use of accounting
4/30/12 6:24:30 PM
 xxx | Contributor Biographies
information. He received his PhD from the University of
Illinois at Urbana-Champaign.
Chapter 10
Lee Ann H. Webster, MA, CPA, FACMPE, has extensive expe-
rience with medical practices both as a practice admin-
istrator and as an independent accountant. Since 1997
she has served as practice administrator for Pathology
Associates of Alabama, PC in Birmingham. She previously
worked in national and local CPA firms, where she per-
formed accounting, auditing, and tax services for clients
in a variety of industries, including a significant amount
of work for physicians and physician practices.
Lee Ann is a Fellow in the American College of
Medical Practice Executives (ACMPE) and a certified
public accountant in the State of Alabama. She is a past
president of the Pathology Management Assembly of the
Medical Group Management Association (MGMA) and a
past chair of the ACMPE Professional Papers Committee.
Lee Ann is a summa cum laude graduate of William Jewell
College in Liberty, Missouri, and earned her Master of Arts
in accounting from the University of Alabama.
Chapter 11
Elizabeth W. Woodcock, MBA, FACMPE, CPC, is a profes-
sional speaker, trainer, and author specializing in medical
practice management. Elizabeth has focused on medical
practice operations and revenue cycle management for
20 years. Combining innovation and analysis to teach
practice operations, she has delivered presentations at
regional and national conferences to more than 150,000
physicians and managers. In addition to her popular e-mail
newsletters, she has authored seven best-selling practice
management books and published dozens of articles in
national healthcare management journals. Elizabeth is
a Fellow in the American College of Medical Practice
Executives and a Certified Professional Coder. In addi-
tion to a Bachelor of Arts degree from Duke University,
Elizabeth completed a Master of Business Administration
in healthcare management from The Wharton School of
Business of the University of Pennsylvania.
Chapter 12
Margret Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR,
CPHIE, FHIMSS, is president, Margret\A Consulting, LLC,
an independent consulting firm focusing on electronic
health record (EHR) readiness, selection, implementa-
tion, adoption, and optimization strategies, as well as
71010_FMxx_FINAL.indd xxx
HIPAA/HITECH privacy, security, and transactions and
code sets assessment and compliance.
Margret’s previous experience includes directing
health information management services at the Illinois
Eye and Ear Infirmary; associate professor, University of
Illinois at the Medical Center; associate executive director,
American Health Information Management Association;
and executive director of the Computer-Based Patient
Record Institute. In 1999, she formed her own consult-
ing firm, providing health information technology (HIT)
consulting services to hospitals, clinics, other providers,
health plans, vendors, and federal policy advisory com-
mittees. She has helped hundreds of integrated delivery
networks, hospitals, and clinics of all sizes select, imple-
ment, and optimize use of EHRs. She currently is also
adjunct professor in health informatics at the College of
St. Scholastica and a principal in Health IT Certification,
LLC. She has written several books on EHR and HIPAA.
Chapter 13
Geraldine Amori, PhD, ARM, CPHRM, DFASHRM, is the
vice president, Education Center for the Risk Management
and Patient Safety Institute. In this role, she cultivates
and coordinates professional development and educa-
tion programs for insurers, brokers, and healthcare and
consumer organizations nationally. In addition, she pres-
ents, teaches, coaches, and facilitates programs about risk
management and patient safety issues.
Previously, Dr. Amori served as principal of Com-
municating HealthCare, which promoted the development
of risk management skills and focused on communication
issues in healthcare. She also served as risk manager for
Fletcher Allen Health Care in Burlington, Vermont. Prior
to that, she worked for nearly 10 years in mental health
direct service and administration.
Dr. Amori is a nationally known speaker, facilitator,
and consultant. She is a past president of ASHRM, as well
as past president of the Northern New England Society
for Healthcare Risk Management. In 2004, she received
ASHRM’s coveted Distinguished Service Award. She has
a Master of Science degree in counseling and human sys-
tems from Florida State University and a PhD in counselor
education from the University of Florida.
Dr. Amori is an advisor to Partnership for Patient
Safety, a board member for the Northern New England
Society for Health Care Risk Management, a member of
the Council for the Madison-Deane Initiative for Palliative
Care, and a lifetime member of the American Society for
Healthcare Risk Management.
4/30/12 6:24:30 PM

Chapter 14
Bruce A. Johnson, JD, MPA, brings both legal and manage-
ment perspectives to healthcare-related legal issues. His
more than 20 years of experience as a healthcare attor-
ney and consultant with the Medical Group Management
Association (MGMA) Health Care Consulting Group
includes providing representation and services to medi-
cal groups, hospitals, academic practice plans, and other
healthcare enterprises in a variety of operational, regula-
tory, and transactional matters.
Mr. Johnson has extensive experience in the applica-
tion of the Stark self-referral prohibition, Medicare and
Medicaid fraud and abuse, tax-exempt organizations,
antitrust, and other legal issues to healthcare business
transactions. He specializes in assisting clients in crafting
effective relationships that promote business objectives in
today’s rapidly changing healthcare payment, delivery sys-
tem, and compliance environments. He is a shareholder
in the healthcare practice group of Polsinelli Shughart PC
law firm, based in the firm’s Denver office.
Mr. Johnson is a frequent speaker on various topics,
including the application of the Stark law, physician com-
pensation and compliance strategies, physician–hospital
integration and alignment, and others. He is the author
of numerous books and articles on healthcare-related top-
ics, including serving as lead author of MGMA’s Physician
Compensation Plans—State of the Art Strategies, and was
the originator of MGMA’s StarkCompliance solutions web-
based product.
Jennifer L. Weinfeld, JD, is counsel at Polsinelli Shughart
PC. Her practice focuses on healthcare law and encom-
passes a variety of contract-related issues, regulatory
counseling, and corporate transactions. Ms. Weinfeld’s
clients have included physicians, physician practices,
physical therapists, hospitals, health systems, and pro-
fessional corporations. She frequently assists clients in
drafting and negotiating contracts including management
services agreements, leased employee agreements, pro-
fessional services and medical director agreements, and
employment agreements for a variety of providers. She
also advises healthcare providers on federal and state
regulatory compliance issues including Stark, antikick-
back, and HIPAA.
Chapter 15
Peter D. Stergios, JD, focuses on labor and employment
law. Mr. Stergios has authored articles, lectured, and
appeared in print and television media on a variety of
71010_FMxx_FINAL.indd xxxi
Contributor Biographies | xxxi
labor and employment subjects, including the effect of
bankruptcy on labor relations, the scope of the federal
laws against disability in professional sports, high-level
executives as discrimination defendants, jury awards in
discrimination cases, labor law developments, ethics for
in-house counsel, alternative dispute resolution, and
mandatory arbitration of discrimination claims.
His representation on behalf of employers includes
labor contract negotiation; project labor agreements;
interest and grievance arbitration; mediation; defend-
ing against strikes, boycotts, leafleting, and picketing;
injunctions; advising employers in union organizing and
corporate campaigns; whistleblower actions; defending
against statutory discrimination claims before federal and
local courts and agencies; designing of agreements man-
dating arbitration of statutory employment disputes and
related advice; noncompete and confidentiality agreement
litigation; counseling as to claims avoidance and statutory
compliance; providing labor strategies in connection with
mergers and acquisitions, and the conduct of related labor
due diligence audits; and defending against court- and
agency-based employment discrimination claims.
Mr. Stergios received his JD from Harvard Law School
in 1972. He is rated a.v. (preeminent) by Martindale-
Hubbell.
Jennifer Itzkoff, JD, is an associate at McCarter & English,
LLP. She focuses her practice on labor and employment
disputes. She has represented and advised a number of
healthcare facilities on their employment practices, includ-
ing internal policies in manuals and handbooks, hiring and
firing decisions, wage and hour issues, employment dis-
crimination claims, and whistleblower retaliation claims.
John M. McKelway, JD, is a partner in the McCarter &
English LLP Labor and Employment Group. His primary
area of practice is labor and employment law, including
preventive counseling, employee relations, arbitration,
litigation, and appeals before administrative agencies and
state and federal courts.
Mr. McKelway counsels businesses and high-level
executives on a variety of topics, including defense of
sexual harassment, wrongful discharge, and whistle-
blowing claims; electronic monitoring and employee
privacy issues; HIPAA and other concerns in the health-
care industry; sophisticated employment contracts and
matters involving executive compensation; labor and
employment issues in mergers and acquisitions; share-
holder disputes in closely held corporations; state and
federal wage/hour matters, including class and collec-
tion actions; union election campaigns and collective
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 xxxii | Contributor Biographies
bargaining issues; pre-employment screening of job
applicants; drug and alcohol testing; concerns involv-
ing AIDS and other disabilities in the workplace; and
ERISA litigation. He has authored numerous articles and
book chapters and speaks frequently on employment
law subjects, including emerging privacy, security, and
liability risks associated with the use of social media in
the workplace.
Chapter 17
Michael R. Costa, JD, MPH, is a senior associate in the
Health Business Practice Group of the 1,200-member
international law firm of Greenberg Traurig, LLP, and
focuses his practice on healthcare and nonprofit corpo-
rate matters. As part of his health law practice, Mr. Costa
counsels various healthcare providers regarding con-
tractual, business, and regulatory matters. He is a fre-
quent lecturer before hospitals, medical practice groups,
and legal associations on both regulatory and transac-
tional healthcare issues and has published extensively
in these areas.
Mr. Costa is a 1997 cum laude graduate of Suffolk
University Law School where he served as technical edi-
tor on the Transnational Law Review. He is also a 2000
magna cum laude graduate of Boston University School
of Public Health, where he was a dual concentrator in
health law and health services management and adminis-
tration. Mr. Costa serves as chair of the Massachusetts Bar
Association Health Law Section Council and as a member
of the communications subcommittee of the Boston Bar
Association Health Law Section. He is also a member of
the American Health Lawyers Association and American
College of Healthcare Executives and is certified in Health
Information Privacy and Security by the American Health
Information Management Association.
Chapter 19
Richard A. Naegele, BA, MA, JD, has practiced law with
the firm of Wickens, Herzer, Panza, Cook & Batista Co.
in Avon, Ohio, for more than 30 years and oversees the
firm’s employee benefits practice area. He is a frequent
lecturer on pension and employee benefits topics and
has published numerous articles in tax and pension jour-
nals. He is a Fellow of the American College of Employee
Benefits Counsel and member of the Board of Editorial
Advisors of the Journal of Pension Planning and Compliance.
Mr. Naegele received his BA and MA from Ohio University
and his JD from Case Western Reserve University.
Kelly Ann VanDenHaute, BS, JD, is an attorney with the
firm of Wickens, Herzer, Panza, Cook & Batista Co. in
71010_FMxx_FINAL.indd xxxii
Avon, Ohio, in the firm’s employee benefits practice area.
Ms. VanDenHaute received her BS from Miami University
and her JD from Cleveland-Marshall College of Law.
Chapter 20
Julie M. Brightwell, BSN, JD, CPHRM, earned her law
degree from The Ohio State University College of Law.
She also completed a Bachelor of Science degree in nurs-
ing and a certificate of nurse anesthesia.
Ms. Brightwell’s experience includes surgical inten-
sive care nursing, nurse anesthesia, and the practice of
healthcare law. She has served as an adjunct faculty mem-
ber on healthcare law issues for a college of nursing and
a legal nurse consultant program. For the past 10 years
she has been a faculty member of The Doctors Company
Risk Management Certification Program, a 6-month dis-
tance learning program for healthcare risk managers. She
has earned the Certified Professional in Healthcare Risk
Management (CPHRM) designation. Her focus as direc-
tor of patient safety programs is on developing patient
safety educational programs for physicians, physician
office staff, nurses, and risk managers.
Dan Bucsko, MBA, MHA, FACHE, CMPE, CPHRM, earned
his MHA and MBA from the University of Pittsburgh and
is certified as an Associate in Risk Management (ARM)
and Associate in Claims (AIC). Additionally, he is board
certified as both a Fellow of the American College of
Healthcare Executives (ACHE), and as a Certified Medical
Practice Executive (CMPE) with the American College
of Medical Practice Executives (ACMPE), and is also a
Certified Professional in Healthcare Risk Management
(CPHRM).
Mr. Bucsko served in the U.S. Navy and Reserve and
retired from the Air Force Reserve at the rank of Major
after nearly 27 years of military service. He has over 10
years of underwriting and claims experience in addition
to more than 14 years of healthcare administration experi-
ence, with many years in clinical settings.
Chris Morrison, Esq, is a health law attorney in Winter
Park, Florida. He received his juris doctorate from the
University of Florida College of Law in 1999. His legal
experience includes medical malpractice and hospital
liability defense, as well as a broad range of healthcare
matters. He currently practices in-house for Adventist
Health System/Sunbelt, Inc.
Darrell Ranum, JD, CPHRM, regional vice president of
The Doctors Company, earned his juris doctor degree
from Capital University in Columbus, Ohio, and gradu-
ated from Mid-America Nazarene University with a BS
in biology. Mr. Ranum has served on many committees
4/30/12 6:24:30 PM

and boards, including the task force that created the Ohio
Patient Safety Institute, the Ohio University Insurance
Institute’s Board of Advisors, and the Ohio Hospital
Association’s Risk and Insurance Management Committee.
He also chaired the Hospital Insurance Forum’s Education
Committee, the board of an inner city charity health cen-
ter, and the American Association for Accreditation of
Ambulatory Surgery Facilities.
Mr. Ranum supervises a group of healthcare profes-
sionals who provide risk consulting services and educa-
tion to hospitals, ambulatory care facilities, physician
groups, and other organizations insured by The Doctors
Company. He co-founded The Doctors Company/OHIC
Insurance Risk Management Certification Program, a
6-month distance learning program cosponsored with
Ohio University Without Boundaries. Mr. Ranum was
recently named Risk Manager of the Year by the Ohio
Society for Healthcare Risk Managers (OSHRM).
Susan Shephard, MSN, CPHRM, director, patient safety
education, The Doctors Company, earned her master’s
degree in Nursing Administration from Medical Colleges
of Virginia–Virginia Commonwealth University. She also
received a Master of Arts in Management from Webster
University and a Bachelor of Science in Nursing from St.
Louis University. She holds the rank of Colonel (retired)
in the U.S. Air Force, Nurse Corps. Ms. Shepard spent
7 years as a nurse and administrator surveyor for the
Joint Commission on Accreditation for Healthcare
Organizations (JCAHO) and was a highly acclaimed
speaker for Shared Visions New Pathways, Ambulatory
Care, and the AHA Continuous Readiness Program in
Tennessee, Alabama, Mississippi, and Arkansas.
Ms. Shepard has over 30 years of leadership experi-
ence in acute care hospitals, ambulatory care systems,
and health maintenance organizations, and in conducting
comprehensive healthcare evaluations. She has expertise
in change leadership, utilization management, complex
organizations, managed care and wellness, staff develop-
ment, strategic vision development and implementation,
and multidisciplinary collaboration.
Chapter 21
Christian F. Bormann, AIA, NCARB, LEED AP, is an
architect who has focused on the planning and design
of healthcare facilities of all scales and complexities. He
studied architecture at Princeton University, and after-
wards was introduced to healthcare facility planning and
design while an officer with the U.S. Army Health Facility
Planning Agency. Chris managed the design of some of the
Army’s largest state-of-the-art teaching medical centers.
71010_FMxx_FINAL.indd xxxiii
Contributor Biographies | xxxiii
After the military, Chris obtained a master’s degree in
architecture from the Architecture and Health graduate
program at Clemson University, which focuses specifi-
cally on healthcare facilities. At Clemson, Chris received
an American Institute of Architects/American Hospital
Association fellowship grant for graduate work. Since
then, Chris has been planning, managing, and leading
the development of complex healthcare facilities and
was a Principal at Perkins+Will in New York City, where
he managed the healthcare practice. Chris resides in
Hunterdon County, New Jersey, with his wife, Holly, and
their three children.
Sonya Dufner, FASID, has for the past 20 years focused on
promoting fully integrated environments for the work-
places of both healthcare and corporate clients. As direc-
tor of workplace in the New York office, Sonya works with
global and national clients in rethinking processes and
standards, bringing research, and benchmarking practical
solutions into modern goals of improving productivity, col-
laboration, and attracting the best talent. Her background
in interior design combined with her planning experi-
ence leads to an approach that synthesizes strategy and
design. Her experience includes projects for clients such
as ColumbiaDoctors, Massachusetts General Hospital,
Mayo Clinic, United Nations, Thomson Reuters, Bank of
America, and L’Oréal USA. Sonya holds a bachelor of arts
degree in interior design from Michigan State University
and is NCIDQ certified, a Fellow and national board
member of the American Society of Interior Designers,
on the advisory board of Design Ignites Change, a profes-
sional member of AREW and CoreNet Global, as well as
a LEED Accredited Professional.
Jason Harper, AIA, LEED AP, is an associate principal and
healthcare architect with Perkins+Will architects in New
York City. Jason’s expertise is as a designer and planner of
healthcare facilities, where he has focused his career for
over 20 years. Jason’s experience includes project manage-
ment, design, and planning efforts for many of the largest
academic medical centers in New York and the Northeast
region, including Maimonides Medical Center, Mount
Sinai Medical Center, New York–Presbyterian, and Johns
Hopkins Hospital. He has also served his clients by lead-
ing many healthcare design and construction projects,
from large-scale new construction to small-scale reno-
vations, at both inpatient and outpatient facilities. Jason
attended Rensselaer Polytechnic Institute in Troy, New
York, receiving both Bachelor of Science and Bachelor
of Architecture degrees. Prior to joining Perkins+Will in
2007, Jason was a principal with Guenther 5 Architects
in New York City.
4/30/12 6:24:30 PM
 xxxiv | Contributor Biographies
John Rodenbeck, AIA, NCARB, LEED AP BD+C, is an archi-
tect who has focused on the programming, planning, and
design of hospitals, clinics, and other healthcare facilities
for over 20 years. He has written articles and spoken at
healthcare events on various healthcare planning subjects.
He has a Bachelor of Architecture from the University of
Cincinnati and was a senior associate and medical planner
at Perkins+Will in New York City.
Richard Sprow, AIA, is an architect who has specialized
in the planning and design of healthcare and hospital
facilities for 30 years. His experience includes more than
71010_FMxx_FINAL.indd xxxiv
200 projects, ranging from small clinics and rural hospi-
tals to major university teaching hospitals and medical
schools. Mr. Sprow has written papers on healthcare plan-
ning topics and has led postgraduate seminars on plan-
ning issues at New York University and at Peking Union
Medical College. He holds a Bachelor of Architecture
degree from Pennsylvania State University and was a senior
health planner with the New York office of Perkins+Will,
where he directed programming, planning, and design
projects for work in New York and China.
4/30/12 6:24:30 PM
Another random document with
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN