Tom Boat navigates change at UC Physicians Featured

8:00pm EDT September 25, 2009

Journeys start with a map and a destination, but Dr. Tom Boat knows he’s not going anywhere until his foot hits the pedal.

His action-ready approach is changing the face of UC Physicians, a physicians group at the University of Cincinnati College of Medicine with 650 physicians and about 1,250 other employees.

The clinical faculty members at the college — where Boat also holds the title of executive associate dean for clinical programs — were operating under 16 specialty practices. Each was like its own corporation with separate accounting, marketing and other functions.

“Unless the clinical practice was better integrated and better coordinated in the future, it was unlikely that it was going to compete as effectively as it had in the past,” Boat says.

The previous leadership tried coordinating the departments twice before Boat’s July 2008 arrival but with no success.

To make it happen, the third time around would require a focus on execution, even if it meant taking smaller steps to find doses of success.

“We’re going to make sure that every step of the way, that step is a step forward and that people recognize it as progress,” Boat says.

Of course, he first had to learn about the company’s starting point. As initiation, he charged managers with outlining the current processes and adding their opinions of what was and wasn’t working.

“I had to get to know the programs and understand what their strengths and challenges were and begin to work with the system at the level that it was at, rather than coming in and saying, ‘I know exactly what to do,’” Boat says. “So tailoring the change process to the situation is really important.”

But then, Boat focused his attention on getting the company where it needed to go. Along the way, data served as his GPS, showing where the company had been and where it was headed. Most importantly, he used it to show that change was indeed manifesting.

“I think that execution in this process is really, in the end, what makes the difference,” he says. “You can evaluate all you want. You can plan all you want. But if you don’t execute on that plan and do it in a successful way, then it probably is going to be a failure.”

Gauge who’s ready for change

You can’t predict every step of your change process, but you at least have to know where to start.

Since the integration idea had already seen two unsuccessful runs at UC Physicians, Boat came on board facing a skeptical faculty. To prove the plan and himself as the new leader, he knew he had to start small. And those first steps also had to be fruitful.

“As you’re talking about change, it really is important to make sure that the first change steps are successful,” he says. “You have to pick and choose carefully. If you take on the really hard stuff right at the beginning and aren’t sure you’re going to be successful, it’s pretty risky. Make sure that your first steps are doable and successful.”

To identify the low-hanging fruit with the highest potential for success, look at who will be implementing the change. At UC Physicians, those were the clinical department administrators, and Boat decided where to start the process by judging their reactions to each suggested change.

“It was a matter of saying to them, ‘Here’s what we think we can do. What do you think?’” Boat says.

He presented the hard facts to the administrators, using monthly scorecards that UC Physicians started publishing before the transformation even began. This data measured things like days in accounts payable and number of rejections. Your managers’ questions, hesitations or excitement about improving the current data is the first measurement of their readiness to change.

But you need to look beyond what they say and examine what they can do.

“You can change the entire practice, but change happens department by department and program by program within,” he says. “And so one of the things that we’re continually assessing is: Do the departments individually have management capability to effect change and to sustain change? The change has got to be durable as well as achievable in the first place.”

Boat expects his change leaders to be able to set and achieve goals and to ignite their employees. For the first piece of that, you can look at their past performance, the previous goals they’ve set and met and their ability to deal with other changes. Continue to monitor that as you charge them with increasingly larger changes.

To measure managers’ motivational skills, go straight to their employees. Boat looks for what he calls “the turbulence factor” in each department.

“One level of turbulence is that the faculty are unsettled, that they’re not getting straight answers, that they really don’t understand the process,” says Boat, who stays in touch with rank-and-file employees to gauge how communication trickles down through managers. “Another level would be discontent and a fair amount of movement in terms of employees within the department.”

Obviously, if employees are flooding out of certain departments, you should see red flags. But Boat also arranges periodic checks, like meetings between his management team and each department as well as town-hall meetings, to catch the less-obvious signals and see where the most misunderstanding lies.

If you’re staying in touch with employees on all levels, you should see which departments are informed and motivated — in other words, ready for change — and which ones are reluctant and unsure.

“The idea is to, as broadly as possible, explain the process and give people a chance to ask questions and to answer those questions,” he says.

Pace yourself

After identifying your change leaders, you need to set the proper pace. If you look at the change process as a journey, you’ll understand that you have to be flexible and pace yourself. What started as a one-year goal at UC Physicians, for example, now spreads two or three years into the horizon.

Sure, some changes got fairly solid consensus right away, and those were easier to execute quickly. For example, the process of credentialing physicians — which includes establishing their qualifications at various sites — was fairly repetitive, not to mention costly and time-consuming, across each department. Most of the leaders agreed that it could be simplified by centralization. So that change was relatively easy to make.

“There are certain things that you can just do by declaration or fiat,” Boat says. “And there are certain things that you have to do by piloting it and picking an area that’s ready for change and has the leadership in place to ensure that that change is really going to be successful.”

Choosing those areas is a combination of two things: Your evaluation of which managers are poised to drive change and a clear plan of what the change will be.

“It comes down to confidence, and confidence is a mixture of this sense that you know how to do it, rather than you have to figure out how to do it and test it, and … the readiness of the programs,” Boat says. “So if everybody is saying, ‘Yeah, we’ve got to do that,’ you can probably push it through fairly quickly. If people are saying, ‘Eh, I don’t know if that’s going to work,’ then taking the more incremental approach is probably the best thing to do.&

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For example, a handful of the departments had honed effective billing and collecting processes, but others were struggling to get on board. So Boat centralized the six departments with more polished systems into one revenue cycle management process. He knew that pushing everyone onto a new financial platform before they were ready could quickly damage the bottom line.

Piloting programs can also serve as a trial run if you’re not entirely sure how the change will look. Using your manager evaluations, start with the departments that seem poised for change. Establish checkpoints upfront so you can track the progress of the pilots.

“Executing on the plan really means that you have to have firm endpoints and you have to have timelines to achieve those endpoints,” Boat says.

Work with experts on each subject in your company to establish reasonable, achievable goals. When you’re piloting an idea as a trial, though, it’s especially important that each step shows obvious progress.

Measure the results constantly against those goals. That requires honesty with the rest of the company, especially when there’s no success to communicate.

“It’s being bold enough to say, ‘We’re going to do this, but we’re also going to be on top of whether it’s achieving what we want or not. And if it isn’t, we’re going to back up and we’re going to take another run at it from another direction,’” Boat says. “Being ready to make mistakes, to recognize them and correct them promptly is important. And to do that, you have to have really good outcomes data.”

You can always readjust goals depending on those outcomes. And, of course, when you do find the right solution, the pilot can also be a demonstration, convincing skeptics to buy in.

“More often than not, we ended up piloting things. And then when people saw that it was useful and successful in other programs, they were much more ready to jump on board and make the change,” Boat says. “There are always going to be skeptics in any process like this, but the more success we have, the less skepticism there will be.”

Show success in numbers

Seeing may not be believing for all the skeptics on your staff, so you have to use hard data to back up successful steps toward change.

If you started recording various metrics before instigating the change, like UC Physicians did with the monthly scorecards, you’ll have a point of comparison to mark your progress.

Boat shares those results in a newsletter called Connected, which began as a monthly but was eventually spaced out to publish about every six weeks. The publication explains the re-engineering process, describes goals and uses data to offer progress updates.

The key is transparency but not so much that all of the data overwhelms your employees.

“You want to be fully transparent, but you can distill the data down into the important points and help interpret,” Boat says. “So in the communications you send out, you don’t just give them tables of data. You say, ‘We’ve collected the data, and here’s what it told us. Here is our reaction to that. Here’s how we’re using that information.’”

Within one year, for example, the company’s operating margins increased by about $4 million. They reached fiscal 2009 revenue of $231 million, up from $220 million the year before.

“Our ability to talk about where we’ve made progress has been important in keeping people engaged, No. 1, and making sure that they see that this is a trajectory they want to continue,” Boat says.

On a broader scope, simply keeping employees updated throughout the process keeps them involved, not to mention motivated.

“Once people began to see that we were able to achieve [growth], I think they felt more comfortable that we’re on track,” Boat says. “Being able to show people data certainly solidified their level of confidence.”

How to reach: UC Physicians, (513) 475-8000 or www.ucphysicians.com