• The Five Steps of Supervision, Part Two: Three Types of Problem Employees

    By Derek A. Preece, MBA

    This article is from October 2006 and may contain outdated material.

    Last month I explained the five steps of supervision.1 As a quick recap, your responsibilities to your employees are as follows: You should 1) provide tools and 2) provide training as needed, 3) help them set goals, 4) be a resource if they run into any unforeseen obstacles and 5) hold them accountable for meeting their goals. The flipside of this is that employees have five corresponding responsibilities.

    This month, I’ll focus on the process of setting measurable goals and reviewing performance. While these two steps can help you to develop high flyers, they also help you to diagnose poor performers and challenge them to improve.

    Performance goals should be measurable. When you first ask your employees to set their own goals, they are likely to propose goals that are ambiguous. But if the goal relates to an aspect of performance that you can’t measure, there’ll be no way for the employee to be accountable for that goal. The goals must therefore be specific and measurable.

    Once employees understand the concept of goal setting, I find that they often set goals far higher than I would have set for them, and I am often amazed at how well they do and how excited they get.

    Ensure Accountability

    Use measurable goals, so staff can account for their performance. Here are four goals, along with ways to judge performance.

    1) Be more friendly with patients—use a patient satisfaction survey and a self-evaluation each day.

    2) Learn to use OCT—successful completion of training plus good results on 15 patients.

    3) Reduce A/R days outstanding to 35—use end-of-month reports.

    4) Reduce patient intake errors—measure errors monthly by categorizing insurance denial reasons, and isolate data entry errors during patient intake.

    Performance reviews should focus on progress. When you sit down with members of staff to discuss how they are doing, you should not focus exclusively on completion of the goals. You should praise an employee who is trying hard to reach the goal and is making progress, even if he or she hasn’t finished the goal by the original deadline. Too much emphasis on goal completion will encourage employees to set unambitious goals.

    Employees who are making good headway on meeting their goals will look forward to their accountability sessions because this is when you give them the recognition that they deserve for their progress.

    Problem Employees

    What should you do when a member of staff frequently forgets to do tonometry during patient work-up? Make sure one of her goals addresses this issue. The problem is solved if she achieves that goal, but what if she fails to improve her work habits? Perhaps she even tries to avoid reporting to you on goals, hoping the issue just dies.

    If your practice is faithfully apply-ing the five steps of supervision that I described last month, then there are only three possible reasons for her lack of progress—she is either 1) untrained, 2) unable or 3) unwilling.

    As you help your staff set goals and then follow up on those goals in accountability sessions, you soon can identify which of those three reasons is responsible for a poor performer’s lack of progress. Once you have identified the problem, the prescription for what to do for that employee becomes obvious.

    The problem of the employee who is untrained . . . Even if the staff member has received some training, he or she may not understand it, or may not have assimilated the training into their daily work. Suppose, for example, you told your new receptionist to ask patients if they want to pay their copay with cash, check or credit card. If he doesn’t follow your instructions, he may not understand why it is important to get the copay on the day of service. Or he may think it is just a temporary policy, or that it’s optional or that it’s to be used only for patients of a particular insurance company

    . . . the solution: If the employee is untrained, the solution is to provide more training until he or she learns that part of the job.

    The problem of the employee who is unable . . . If the new receptionist has been provided with all appropriate training and he still cannot meet the goals set for improvement, he may simply be unable to do that job

    . . . the solution: I would work hard to salvage someone whom I have hired for a position that they are unable to do. As long as they are trying hard, I will do everything I can think of to make the situation work. Sometimes a practice can find a more suitable position. Suppose, for instance, your new receptionist doesn’t have the personality to deal with patients all day in a pleasant, friendly way. Although he’s not people-oriented, he may be very task-oriented —in which case he might make a good biller. But if a more suitable position isn’t available within your practice, you may have to terminate the person’s employment. Any employee who consistently is unable to achieve his goals is better off in a different position where they can be successful, rather than continuing in a job where they know they are failing. In addition, your practice is better off having someone in that position who is able to do the work.

    The problem of the employee who is unwilling . . . Suppose an employee’s performance is poor even though he has been appropriately trained and is able to do the job the way it needs to be done. He has set himself goals for improvement, but is simply making no effort to change and improve. In this case, the person is unwilling to do the job the way the practice needs it to be done

    . . . the solution: I had a situation once where a tech let her usual good attitude disintegrate into bitterness during her divorce. When she was confronted about this, she realized how miserable her work habits had gotten. She immediately changed and became a model employee. But that was a rare exception—most unwilling employees won’t change. If you have candidly brought up the fact that they seem unwilling to do their job as required, and if they don’t offer some evidence of a change of heart, your practice would be better off without them. And if you have been using the five steps of supervision as described last month, you will have documentation to support the termination, much of which will be in the person’s own handwriting.


    The management system that I have described can help mediocre performers improve and high achievers blossom, because the goal setting and evaluation sessions provide them a sense of achievement and recognition, two things that everyone craves.

    Poorly performing employees, on the other hand, will not like this system. People who really don’t have their heart and mind in their work don’t want the pressure of improving by setting goals. And they definitely don’t want to be held accountable. Eventually, they will seek employment elsewhere—effectively firing themselves.


    Mr. Preece is president of Enhancement Dynamics Inc., a practice management consultancy based in Orem, Utah. For the consultancy’s contact information, visit the AAOE Consultant Directory at www.aao.org/aaoe.

    Visit the Online Forum

    E-EXPERT. Earlier this year, Mr. Preece moderated a discussion on management systems as part of E-Expert, which is an online forum where AAOE members can discuss a new topic every one or two weeks. Here are some brief excerpts from that discussion.

    ON SYSTEMS. Discussant:Whatever the system is, the goal is quality. And quality comes from the repetition of a series of actions that result in a predictable desired outcome.”

    Mr. Preece: “That was a concise statement of a very profound principle. We put systems in place throughout the practice so that the outcome will be predictable and of high quality. If, for instance, every step of our billing process is done correctly (high quality) then we have the highest chance of receiving payment.”

    Discussant: “[When you use a system] the variables that do not fit the pattern can be addressed as they occur. Most energy is expended upon planned, rather than reactive, work so that quality is maintained.”

    Mr. Preece: “I have found that using a system of management helps me to identify when I’m going astray and what I ought to be doing.”

    ON GOALS. Discussant: “Long ago, someone came up with the acronym of SMART for goals: S for specific, M for measurable, A for attainable, R for realistic and T for time oriented. I always try to use these guidelines when staff set goals. I have had people put ‘I want to be a better tech this next year’ as a goal in the evaluation process. Pretty hard to judge progress for this type of goal.”

    Mr. Preece: “I also use the SMART idea when I train offices on the five steps of supervision, because it helps qualify the appropriateness of the way a goal is stated.”