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Dynamic Chiropractic – January 15, 2005, Vol. 23, Issue 02

Create a High-Performance Team

By Mark Sanna, DC, ACRB Level II, FICC

This is the first of a series of articles based on Dr. Sanna's book, Breakthrough Thinking.

It's not the big things, but the small details that let you know your team is not functioning at its peak.

How often have you wanted to wring a practice team member's neck at the end of the day? How often has a team member wanted to wring your neck? How many of the following "famous fumbles" have you experienced in your practice?

Famous Fumbles

  • A patient's file folder has completely vanished and no one can find it.
  • There are four patients waiting to see the doctor, who is locked in the treatment room with a "favorite" patient.
  • A patient won't schedule a visit, doesn't have his or her checkbook, and the front-desk assistant says, "That's OK. Just send us a check when you get home."
  • Someone forgets to tell the doctor that there is a new patient ready and waiting in the exam room.
  • You suddenly think, "What ever happened to our wonderful patient Mary Brown?" Then you find out that she hasn't been in for a visit in the past two years!

Low-performing practice teams lack focus on a collective purpose. Each team member may well have a unique purpose of his or her own, but the team as a whole lacks a unifying vision. In an "every man (or woman) for himself" atmosphere, the collective purpose is buried beneath blame, finger pointing, nitpicking, and gossip. Without harmony, the team struggles to produce uninspiring results. They use time and energy inefficiently, don't like being at work, and have little fun. The team complains of feeling "stuck" and of being unsatisfied with their positions.

High-performing teams, on the other hand, share a strong sense of common purpose. They communicate well with each other. They build a climate of trust, openness, and honesty. High-performing teams welcome ongoing coaching in the skills, procedures, and attitude that generate success. They share a common game plan, and continually train, drill, and practice. They share responsibility and take credit for the success of the team. High-performing teams consistently produce excellent results.

Teamwork Starts at the Top

Best-selling business author Ken Blanchard says, "None of us is as smart as all of us." Effectiveness is greater than the sum of its parts, but the effectiveness of a team can be no greater than the effectiveness of its leader. Leaders set the pace. Great leaders know that team members don't care what their leader says - they care what their leader does! Great leaders set an example. They hold themselves to the same standards they expect from their team members, knowing that applying a double standard results in distrust and the appearance of hypocrisy. Great leaders act as coaches by providing ongoing training and feedback for their team. They practice leadership in attitudes and actions, not merely in words.

Teamwork Begins With Purpose

Your purpose is the clearly stated direction you have consciously chosen for your practice. Your purpose answers the question, "What is our reason for being?" It's your responsibility as leader to define your team's purpose.

Purpose and person are often inseparable. The best leaders lead by principle, not policy. They are committed to their purpose. They share their purpose with their team. They follow three principles to guide them in formulating your purpose: They do what is right, they get results, and they do it together.

Check Your Team's Purpose

Team members who do not share the purpose of the rest of the team are often motivated to work by their paycheck. They generally look for satisfaction outside of the practice. These team members are "time-clock watchers" who give the practice their time, but not their energy. They don't consider how their actions affect their teammates, which results in a high level of absenteeism. Practices with a low sense of shared purpose typically show low numbers of office visits, new patients, and referrals.

Team members who share a common purpose work for a cause and not just a paycheck. They find satisfaction both in and outside of the practice. They give both their time and their energy, often staying late to finish work, share new ideas, or refine procedures. Team members who share a strong sense of purpose are considerate of their teammates and go out of their way to make sure everyone's needs are met. They come to work regularly and stay for the long term. These practices typically exhibit a high volume of office visits, new patients, and referrals.

Three Stages of Team Growth

A team matures through three stages of growth. The first stage is dependence. In the dependent stage, team members are learning their jobs and depend on their leader to provide a sense of direction. The relationship between team member and leader is similar to that between a parent and a child. Just as a child requires constant supervision, feedback, and correction, dependent team members need the attention of their leader. Team leaders should use a "tell" rather than an "ask" approach, providing frequent feedback, meetings, training, and testing of new skills. Leaders should follow up to assess each team member's competence on newly learned procedures. Role-playing in areas like telephone techniques is often helpful.

The second stage of team growth is independence. In this stage, team members perform well on their own and master their performance by repeating procedures again and again. The relationship between leader and team member is more like a parent-adolescent relationship. In the independent stage, team leaders should favor two-way communication, giving more responsibility and discretion in decision-making to team members as they progress. Leaders should be ready to ask for suggestions and opinions. Independent team members have earned the right to express opinions, refine procedures, and offer new ideas. Follow-up must be oriented more on outcomes, rather than procedures or techniques. For example, the leader might measure the rescheduling of missed appointments rather than proficiency with telephone scripts.

Beware of the independent stage pitfall! If team members are allowed to progress to the independent stage before they are prepared, they start to "wing it," innovating and changing procedures on their own. Independence requires a mastery of the essential functions of the position. Team leaders must be sure that a team member is ready to work independently before granting this responsibility.

Team members are proud to be independent, and team leaders welcome the freedom from supervising that independence allows them. But don't rush things. While there are benefits to independence, a team that is prematurely expected to function independently gets stuck, grinding out lackluster performance and never achieving the "Wow!" of a highly tuned team.

Even suitably independent teams must look to the future and the third stage of progress: interdependence. An interdependent team member becomes part of a community. The leader is a "parent" to the "adult child" team member. Everyone, leader and team member alike, depends on each other in a collaborative relationship. The leader establishes the parameters, solicits feedback and input, gives increased responsibility, and establishes guidelines for growth. Follow-up and evaluations are based on departmental and organizational outcomes, rather than on procedural outcomes. For example, the marketing department might be evaluated in terms of its success in attracting new patients and the finance department evaluated in terms of its percentage of collections. Interdependence is the result of time and experience. It arrives only after many hours of meetings, training, and practice. Interdependence doesn't just happen - it is earned.

Develop High-Performance Players

Over the years, players on your team will come and go. When assembling or adding to your team, don't rush headlong into the process. You are not looking for "just another" team member. You are looking for the most worthy teammate, so don't hire simply because you feel pressure to fill a vacant position. On average, you must interview a minimum of 18 candidates to find one right person. Don't give up after the first, second, or third round of interviews!

It is equally important to winnow out unsatisfactory team members. Many practices find that their best efforts are sabotaged by a team member who doesn't belong on the team. Due to their altruistic nature, most health care providers feel that they can "fix" anyone. But don't kid yourself: A team member who consistently performs poorly will bring down the performance of your entire practice. By all means, give everyone a fair chance to become part of your team. But when necessary, let a low-performing team member go so that he or she may find a team on which to excel. This is part of the responsibility of the team's leader. Leaders can't afford to lose the respect of their team simply because they neglect to do something about a team member everyone knows doesn't belong.

Confirm Players' Positions

Do you have written job descriptions for your practice team? Have you read these descriptions? If not, establish clearly defined job descriptions for each team member. Set measurable expectations and results for each position. Ask your team to describe their jobs back to you. Continually train, drill, and practice core procedures. Be sure that your team members know that you are evaluating their performance.

The greatest barrier to teamwork is low trust in the leader. Trust takes a long time to achieve and it can be destroyed in a few seconds. You cannot order others to trust you. They need to experience trusting you. Your team must know that their leader will not change the rules in the middle of the game. If you have ever returned from a practice management seminar and implemented a new procedure without first presenting it to your practice team, you know the negative response surprises can produce. Be sure to involve your team when adding new procedures or protocols to your practice.

Communication is the great team builder - ongoing communication. In the words of George Bernard Shaw, "The danger in communication is the illusion that it has been accomplished." Leaders must establish clear lines of communication in their practice. They are responsible for setting the communication priorities for the team. If you don't want discussions of the weather, sports, politics, or anything that appears on the "E" Television Network to derail your team, make them clearly taboo, unless they can be specifically tied to improving your patients' experience. Make it clear that nonpriority communication "is not the type of communication we want in our practice." Encourage the kind of communication that the team will be proud of at the end of the day.

Strengthen the communication in your practice by holding regular meetings and training sessions with your team. In these meetings, review both the successful and unsuccessful things you have done. Prepare for these meetings. Never hold a meeting without publishing an agenda for it in advance. A good rule is to set aside the equivalent of 10 percent of your patient care hours for team training and meetings. For example, if you see patients for 36 hours per week, devote at least 3.6 hours to coaching the team.

Delegate, Delegate, Delegate

Delegation accelerates team performance and frees us to devote time to higher priorities. You will never have an empowered, self-directed team unless you are willing to share control. Without delegation, you can expect results to be poor and your team will never reach the interdependent stage of development.

Follow-up is delegation's twin. When you follow up on the tasks you have delegated, you remind your team that you are serious about responsibility and accountability. Follow-up keeps your team heading in the right direction - toward the goals you have chosen. It identifies who is doing well, who needs additional training, and who should consider a different line of work. It also builds a bond of mutual respect and trust between you and your team.

The first thing you must do is decide to delegate. Team leaders are too often tempted to fall into the "only I can do this right" trap. Ask yourself, "Is it more important that I do this job, or that it gets done?" Re-read your team members' job descriptions and be sure that you are not performing tasks that should be performed by someone else.

Delegate only complete tasks. It is more satisfying to work on a complete task than on a fragment of a task. Remember, you delegate a task to remove the workload from your plate. If you delegate and receive back partially completed tasks, you have to invest your time in completing them. Your team members will not develop the confidence to do the job themselves, and they'll stay stuck in the dependence stage of development.

When you delegate, clearly explain the results you expect. Assume nothing. Get confirmation and agreement on the results you expect and the importance of the job to the big picture. Set reporting dates for updates on the progress of the project and set a deadline for completion of the task.

Your follow-up will be effective only if you know what you have delegated, and to whom. Use a delegation log for keeping track of the tasks you have delegated and the team member you have delegated them to. A delegation log is a list of the tasks that you have delegated, to whom you have delegated them, interim progress dates, and the expected dates of completion. Review the delegated tasks when you receive the scheduled interim progress reports. This is the one of the most commonly skipped step in the delegation process, yet it is also one of the most important. If you fail to check on the progress of a project on a scheduled date, your credibility will suffer. Even in the independent stage, team members will test you, just as an adolescent tests a parent. They want to see that you keep your end of the agreement, too. Following up is your responsibility as the team leader.

Once you delegate, let go! Trust your team member to get on with it. Review the project on the agreed reporting dates, but don't look over shoulders constantly. A team member may know a better way of doing something than you do. Accept mistakes - as long as they are not the result of idleness, mistakes offer lessons that successes cannot.

Give Credit When Due

Give public recognition and acknowledgement. It reinforces success and provides an incentive for the rest of the team. Don't think that money is the only form of acknowledgement. Hold in-house awards ceremonies, mini-celebrations, and luncheons. Offer non-monetary gestures of thanks for contributions - for example, theater tickets, a day off, a gift certificate, or a dinner for the team member and his or her spouse. Give awards liberally for things like perfect attendance, volunteering for a practice-building project, displaying contagious enthusiasm, submitting a cost- or time-saving idea, going "above and beyond" for a patient, or simply keeping cool under pressure. Be creative and never miss the chance to acknowledge a job well done!

Commit to Creating a High-Performance Team

Motivation is never a problem when your team members feel they are moving forward, learning new skills, and stretching their minds. But they will only sustain motivation over the long haul if they are aligned with a shared purpose, feel a challenge in their tasks, and experience growth - individually and as a team.

You'll have a high-performance team when you provide a strong sense of purpose to which the team is committed; when you have placed the right people in the right positions; when your team becomes truly interdependent; when you continually train, drill, and practice with your team; and when your team communicates clearly and you delegate confidently. You'll know you have a high-performance team when your team acknowledges and celebrates its accomplishments without your prodding!

Mark Sanna, DC
Miami, Florida

Dr. Mark Sanna, a 1987 graduate of New York Chiropractic College, is a member of the ACA Governor's Advisory Board and a member of the President's Circle of NYCC and Parker College of Chiropractic. He is the president and CEO of Breakthrough Coaching (

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