This meme popped up on one of my feeds recently, and whenever it does, it makes me smile (and think).

It’s a picture of a horse tied to a lightweight plastic chair. The horse is standing patiently and obediently, presumably unaware that he could easily shake off the chair, break it, or drag it along and run away if he chose to. The caption is always some variation of, “The thing holding you back might be all in your head.”

Time to break free?

It’s an idea always worth exploring in my opinion. Whenever working on an intractable problem, I always seem to find that testing some assumption or another can lead to a solution.

It’s natural for business owners and managers to rely on assumptions. No one has time to rethink every workflow or financial policy or technology strategy every day (obviously). That’s one reason why unhelpful or outdated assumptions can be hard to spot. It’s a challenge that affects everyone, but perhaps especially very busy people who shoulder a lot of responsibility.

What’s more, “if it ain’t broke, don’t fix it” or “that battle’s not worth fighting” or “we tried that once and it didn’t work”–some of the most common assumptions we make to help us keep things moving along—can be very useful maxims that help keep the to-do list manageable and avoid wasting energy.

Even well-founded assumptions can outlive their usefulness as times change, though. And when they do, the same guideposts that once were so helpful can undermine progress. Part of my job as a consultant is to help practices identify and question their assumptions, to be sure they’re still helpful.

A mini case study

I saw this play out recently with a practice that wanted to add clinicians but lacked office space, especially at the front desk. As a result of earlier expansion of the provider team, the front desk was already understaffed by at least fifty percent. (“We can’t fix that. There’s nowhere to put anyone else.”)

Despite this obvious constraint, the owners had an opportunity to hire two clinicians they really liked, so they went ahead and did so. (I can see why. Good clinicians who want to work in private practice can be very hard to find!) But the risk was that the already overtaxed front desk employees (who handle scheduling, over-the-counter collections, phones, and check in, plus various other duties) wouldn’t be able to handle the increased load.

Unfortunately, that’s exactly what happened. The front desk went from stressed to stumbling.

Phone calls went unanswered. Slow-moving lines formed at check-in. Patients at the front desk felt ignored or undervalued, as staff interrupted their interactions to try to keep up with the phones. Patients were even sometimes forgotten while waiting in the reception area.

Patients complained about these things online—and to their doctors, who then complained about the front desk. Unfortunately, that only added to the stress.

Turnover at the front desk (already a problem) became much worse. The overworked manager’s “occasional” filling in became a regular occurrence. That meant his management duties—critical things that only he could do—were not getting done on time.

Consulting input

My clients and I discussed a few possible adjustments to the layout to create an additional workspace at the front desk. All were quickly ruled out as unfeasible. That turned this situation into a much tougher problem. We weren’t going to solve it with a hiring blitz.

The owners and manager had been contemplating a new, larger office space for a while. They wondered out loud if this was their only path forward. This would take months to accomplish, though, and it would be costly to say the least. And how could they put up with these problems in the meantime?

Consequently, I suggested a somewhat novel solution that wouldn’t require more space: hiring remote schedulers.

This idea could be implemented fast. The practice already had a phone tree that would allow patients to direct themselves to the “scheduling department,” even if that “department” was a team of people working from their homes.

Remote scheduling would have a few additional advantages beyond solving the capacity problem. Dedicated schedulers could confirm insurance and enter demographics at the time of scheduling—which would reduce billing errors. Peeling off the scheduling calls would radically reduce the call volume, thereby improving the patient experience at the front desk. (Many calls during the day were repeats. Answering patients’ initial calls would cut down the total volume on a much greater than one-to-one basis.)

The manager was also bothered by missed calls from prospective patients. Ensuring those calls were answered could bring in new revenue (and profit) quickly.

Frustratingly (to me), despite the upside, the partners and the manager dismissed the idea.

Their reasons:

1) “We once allowed a nurse to work part-time at home. Several other nurses resented it and raised a fuss.”

2) “It’s too hard to manage remote workers.”

3) “We need to cut costs.”

4) “We need front desk staff to do all the jobs: phones, scheduling, check-in, and more. Those can’t all be done off-site.”

Questioning the underlying assumptions

Each one of these objections involves an embedded assumption that needs testing.

Consider objection #1. The issues that were created when a nurse was allowed to work some hours at home were worth revisiting. Would establishing a remote scheduling team lead to the same problems?

I saw multiple paths to avoid reliving the morale issues. One idea: scheduling jobs could be set up as part-time only from the outset, rather than a hybrid role for existing staff. (Nobody would be irritated by watching a colleague walk into the office after lunch, imagining they were refreshed after a morning at home “taking it easy.”)

Or they could instead let staff rotate as schedulers, with all being offered the opportunity to work one day per week from home.

Or the practice could hire an outsourcing firm that fills these roles for many practices. This would reduce the problem of comparison and suspicion among employees, since the job would no longer exist inside the practice.

Objection #2, managing a remote team, was also a legitimate concern. But the assumption that a remote team would be harder (or impossible) to manage is also worth questioning.

Scheduling and phone work are very measurable. Using phone-system reports, the manager could confirm whether inbound calls were being missed at the scheduler’s extension. He could also use the practice management system to track how many appointments were scheduled, whether eligibility was checked, etc.

With a set of straightforward metrics, managing remote schedulers might be easier than managing the team at the office, since it would be an objective, numbers-driven process from the outset.

Objection #3, concern about costs, is perhaps the most common reason our practice clients initially reject new ideas. But this was straightforward to address based on simple math.

Adding providers always increases support needs—if not right at first, then eventually. Long before adding these two new providers, this practice had already added providers without increasing support. The signs of an over-stressed workflow were already evident. Adding more providers without more support was bound to push the system over the edge. It took only a couple of weeks after bringing in the additional clinicians to see this.

The strain at the front desk was clearly costing the practice revenue from missed front desk collections, negative reviews, and abandoned new patient calls. Staffing the front desk appropriately would allow the practice to make all the profit it anticipated from the new providers.

Finally, objection #4 was perhaps the stickiest. Neither the manager nor the owners felt comfortable switching up jobs and workflows. “If it ain’t broke…” they liked to say.

But here was the problem: the current situation very clearly was broken.

By their own assessment, they were losing prospective patients. (Never a good thing, but much worse when trying to fill the schedules of new clinicians!) Problems at the front desk were leading to turnover, a tense atmosphere in the office, bad reviews, and complaints. Even if the space constraints weren’t a factor, these other issues also suggested the job definitions and workflows might be in need of an overhaul.

Truth be told, “if it ain’t broke, don’t fix it” can be one of the more trouble-causing assumptions in a practice business. It’s a built-in argument against change… and because change is often what we fear the most, it’s an argument that can be too readily embraced.

There are rational reasons to be wary of change. Changes that don’t work out can be disruptive. But when it’s clear change is needed… it’s important to act. When analysis shows things are falling apart, and especially when it’s clear why, fear of making things worse shouldn’t prevent corrective action.

Bottom line: sometimes, things that ain’t broke actually are. Sometimes, very obviously (like in this case). Other times, more subtly–but even in those more nuanced situations, change can head off problems and improve your results.

For example, keeping up with technology change can be a hassle, but it also has the power to make your practice more efficient and profitable. It can also keep your service level in line with the changing expectations of your patients. Similarly, keeping up with trends like remote work can help your practice stay effective by today’s measures of what it means to be “not broke.”

How the story ends

I’d like to say that I concluded this project with the practice embracing the possibility of trying a novel solution to their problems. But as of this writing, the practice is still limping along with its assumptions intact. The partners decided to focus on acquiring a larger office. On the plus side, this will allow for more growth in the future. But the process would mean a year of disruption, much more work for the manager, and a lot of pain in the meantime.

More important in my view: acquiring more space without examining workflows, trying out new tech solutions, and leaving other assumptions unchallenged will allow them to run at least a little more smoothly, but it will almost surely leave money on the table.