GUIDELINE TO FOLLOW:

1. Introduction
2. Leadership Assessment
3. The Contextual Factors in the Case
4. The Required System
5. The Emergent System
6. The Gap
7. Recommendations

The Impact of Profitability on Leadership and Accountability in a Public University Dental Clinic By Annelise Y. Driscoll and Myron D. Fottler INTRODUCTION The Southern University dental clinic was built with student monies from a capital improvement fund. It took 1 year to design and build, using state-of-the-art technology and the latest in equipment and services. It was opened for students, but faculty and staff were welcome to use the facility on campus as well. This was particularly attractive to all, as the fees for the services were set at the lowest percentile for the region. Therefore, it was in high demand from the opening day until the last day of the first year of operations. At first, faculty and staff were skeptical, but word-of-mouth marketing on the high quality of care, high levels of comfort and service toward patients, and low fees soon spread around campus, and the schedule was full almost immediately. All aspects of the design and build-out of the dental clinic came from the Dental Consultant who was hired to handle the project from inception to opening day, including establishing systems, hiring staff, designing protocols, setting fee schedules, and choosing equipment/technology/dcor. The Dental Consultant had 30 years of experience plus the operational aspect of managing newly built dental clinics. She was responsible, well respected, and given full authority for the project with very little oversight from the Leadership Team from the first discussion to the opening day. She also provided monthly progress reports that were acknowledged with praise. Since no one in the Leadership Team had any background or experience in dental offices, systems, design, or operations, they relied heavily and totally on the experience and reputation of the Dental Consultant. The project went off flawlessly, with the clinic built in less than the allotted time and under the $550,000.00 earmarked budget. The consultant then became the Founding Director of the Dental Clinic. The clinic was built with no debt load, paid for with student money, and had the responsibility of being financially self-sustaining within the first 18 months and thereafter. No subsidies were to be provided for its operational costs, which the consultant knew and took into consideration when creating the operational systems that would lead to financial viability with high demand. All of the key concepts were included in the operational systems: 1) Access to care in a convenient location on campus, 2) high-quality care by experienced and nurturing staff using the latest technology, and 3) low-cost services able to be provided to students, faculty, and staff due to the fact that no debt load was incurred. Coupled with a strong marketing and promotional plan, and a myriad of financing options for all patients, the dental clinic was destined to succeed. During the building phase, the Dental Consultant worked with the Human Resources department to contract with the employee dental insurance companies as well as the student dental insurance program. In addition, the consultant promoted and marketed the opening across campus to colleges, departments, student groups, faculty, and key leaders. The Dental Consultant incorporated private practice profitability and operational strategies while working within the parameters of a state university public setting. This was a unique concept, and admittedly a risky one, but one that succeeded financially almost immediately. DENTAL CLINIC SETTING AND ENVIRONMENT The Dental Clinic was housed within the Student Health Center in the middle of campus. It included 2,000 square feet of space with the reception room, administrative offices, and clinical areas. It utilized state-of-the-art technology and advanced digital imaging systems as well as paperless electronic health records and a fully integrated software system that encompassed both the clinical aspects and business aspects of a patient's chart. The reception room contained a flat-screen TV with dental educational software viewable by patients waiting. Each patient's electronic chart contained an electronic patient information and check-in system, digital images of referral letters, patient identification and insurance cards, HIPAA/FERPA, and all consent forms within the patient's electronic record, and digital signatures from each patient. All papers and documents were stored in each patient's electronic "document center" within their accounts that were built into the dental software. Insurance claims were filed electronically, payments were processed electronically, and patients' appointment confirmations were completed electronically, as well as all aspects of their financial accounts. This created a streamlined approach to viewing all aspects of a patient's chart at a finger-touch from any computer within the administrative or clinical area. The clinical area consisted of state-of-the-art technology used in every aspect of the clinical experience for patients. Advanced technology used in the clinical area included a digital X-ray system, intra-oral camera for a virtual tour of the mouth, voice-activated periodontal charting, wireless headphones to watch TV while undergoing procedures, flat-screen TV monitors overhead to view patient X-rays, photos, educational programs on dental procedures, computerized work stations in each clinical room ("operatory"), wireless handpieces and equipment, an oil-less and maintenance-free mechanical room, automated lights, motion-sensitive electricity, and a high-tech sterilization center. The dental chairs looked like black leather lounge chairs with no trays/or dental equipment looming over a patient's chest while in the chair and all drills/suction/equipment placed behind the patient's head so not to view it or feel claustrophobic while undergoing treatment. Each clinical room, or operatory, used an open-bay design, again, to decrease apprehension and invite relaxation. The soothing aesthetics, coupled with the aromatherapy, was a natural extension to the warm reception room. Patients were put at ease upon entering the clinical area, which quieted nervous patients and created a positive dental experience. Photos were taken on each patient of the inside of their mouths during their virtual tour and were added to insurance claims to substantiate claims. At the same time, patients were confident of explained dental issues when able to view them directly overhead in close view and receive a copy of their photo, if desired. Photos of dental issues confirmed the need for treatment, which increased case acceptance of recommended treatment. This contributed to the significant success of the dental clinic within its first year of operations. Visual proof of the need for dental treatment, the soothing environment, and the low fee schedules for treatment insured the growth of demand early on. The dcor of the dental clinic was very soothing, and cozy, with little reminders to patients of their presence in a dental clinic. Warm colors, soothing art and dcor, blankets, aromatherapy, and natural lighting were used to reduce patient apprehensiveness. Unlike the rest of the health center, which had a more "sterile" and "colder clinical" feel to it with minimal dcor or warmth, the dental clinic was designed to soothe and welcome patients as an integral strategy of patient comfort first. It worked wonders, as patients felt at home and comfortable in the dental clinic. The dcor and atmosphere was unique and other departments requested similar dcor and aesthetics within the health center. Visitors immediately complimented the warm dcor and feel of the dental clinic. It became nicknamed the "Taj Mahal" of the health center. No expense was spared in the design, build-out, and decoration of the dental clinic, yet the entire project was completed in less time than originally estimated, with no issues or problems, and cost less than the proposed budget for the job. As a result of the "private dental practice feel" and the streamlined processes, along with the reduced fees (for students as well as faculty and staff), and emphasis on customer comfort and service, over 3,500 patients were seen within the first 12 months, with a total revenue of over $625,000 in dental services provided. Of those services provided, more than 93% of services were paid for and collected. This went beyond the usual collection ratio of 40% ($0.40 collected out of each $1.00 billed out) that the other departments of the health center collected for the services they provided and billed out. The profitability of the future of the dental clinic was extremely attractive to the Health Center Director as a future source of revenue to subsidize other nonprofitable departments and services. Within a month of opening, the dental clinic was touted as the "rising star" of the health center. DENTAL CLINIC STAFF Dental Clinic Director: After an outstanding job creating and building the dental clinic, the dental consultant was hired as the founding Director. A PhD, with an MBA and 30 years of a successful track record, references, and experience building and operating profitable dental clinics in both private and corporate settings, the Director had the responsibility of establishing financial sustainability and viability of the dental clinic almost immediately. Pressure was applied early on from the Health Center Director to establish policies and procedures based on established best-practices while complying with all regulations. The Dental Director reported directly to the Health Center Director and was on a lateral placement on the organizational chart with the Business Director. The founding Director had worked on campus for 7 years prior in health administration research and teaching and was well known and well liked at the university. She worked well with the construction and design teams as well as other departments within the university during that time. No conflicts arose with any parties during the building of the facility. Dentist: The Dentist brought 15 years of private practice ownership experience with him plus an additional 3 years of working as a dentist for a busy corporation serving mostly an HMO population. After 15 years of owning his own practice, and declining revenue from an impending recession, he sold his practice and worked for a corporate practice. Not wanting to continue working in a corporate dental facility with long hours and significant pressure to "sell" dentistry, the position as the first university dentist at Southern University was an attractive offer; although the university dental salary was two-thirds lower than his corporate salary. The dentist had experience in providing high-volume dental services and understanding the importance of his role in working with and for the Dental Director in creating financial sustainability of the fledgling program. The Dentist reported to the Dental Director for operational matters and the Medical Director for clinical issues not addressed in the existing clinical policies manuals. The Dentist agreed to provide a very comprehensive set of dental services to patients to avoid the need to refer them out to specialists. Financial Counselor: The Financial Counselor brought 15 years of corporate and dental practice administration experience with her. A perfectionist with an outstanding work ethic, she maintained all patient accounts, payment, and insurance billing functions. All patients met with the Financial Counselor at their check-out process to pay for their services or set up payment plans and sign promissory notes for them. Extremely professional and efficient, she was an over-achiever with high expectations of herself and others. The Financial Counselor was aggressive in nature with very high career goals. Office Assistant: The Office Assistant brought 5 years of front desk experience working part time in a dental specialist's office. While she had front desk and dental software experience, this was her first job with all of the front desk responsibilities on a full time basis. As English was not the Office Assistant's first language, her propensity for spelling and grammar errors quickly became apparent. Dental Hygienist: The Dental Hygienist had 6 years of experience working in a fastpaced, high-end private dental practice where there was significant pressure to produce significant revenue. She was experienced, with a warm and likable personality and brought with her an extensive background working with state-of-the-art dental technology. Ambitious and taking on a natural role as technical trainer/expert, she became an informal clinical leader. Dental Assistants: Two Dental Assistants, both of whom worked for the Dentist at his prior corporate dental practice, came to work at the Southern University Dental Clinic, per the request of the hired Dentist. Both Dental Assistants had 3 years' experience as Dental Assistants, working with the Dentist at his prior corporate dental practice. They had limited experience in a fast-paced environment, worked well together, and were extremely loyal to the Dentist. Both Dental Assistants were able to "sell" dental services and were accustomed to receiving monthly bonuses in their prior jobs as an incentive to get treatment acceptance from patients. EXECUTIVE LEADERSHIP TEAM This group of healthcare executives included the Health Center Director, Medical Director, Nursing Director, IT Director, Pharmacy Director, Administrative Assistant, Dental Director, and Business/Financial Director. Meetings were held every 2 weeks, and all major decisions were voted on and approved through the Leadership Team. In addition, individual meetings were held between the Health Center Director and each member of the Leadership Team every 2 weeks to discuss departmental issues and performances. The Leadership Team, with the Health Center Director at the helm, discussed and resolved through voting, all major decisions regarding all aspects of the operations of the Health Center. All meetings were documented by the Administrative Assistant, and all meeting minutes were sent out to the Leadership Team within 24 hours of each meeting. These protocols and procedures were approved and documented by the University Vice Presidents, and were an integral aspect of the fulfillment of the accreditation standards for performance improvement plans. The function of the Executive Leadership Team served to have checks and balances in place, as well as an overall consensus of all key leaders to be made aware of all major issues, situations, and successes, and strategize cohesively on solutions and planning. In addition, all policies, protocols, and procedures were approved unanimously by the Executive Leadership Team. BACKGROUND AND CHRONOLOGY The Dental Clinic was built with no issues, no problems, with the entire project taking less time than initially estimated (12 months instead of 18), coming under budget than originally proposed ($535,000 instead of $612,000), and opened 9 days before Christmas as a "soft opening." One hundred fifty-five patients were seen in 9 days as the staff dealt with new demands for services, urgent care appointments, and performed root canals and crown preparations right up until the close of business on Christmas Eve. The staff expressed concerns about the busy schedule and not wanting to work on Christmas Eve. January was busier than anyone expected as the Director had spent the 9 months prior to opening day on marketing and promoting the Dental Clinic all over the Southern University campus and in various media advertising. As a result, the demand was immediate and higher than originally estimated. Also, the poor condition of the majority of patients' dental condition and oral health surprised all staff and required the Dentist to provide the extensive array of services to treat patients "in house" as much as possible almost immediately. Affordability being a key marketing factor, the wider array of services provided "in house" by the Dentist (as agreed to in his job interviews) became needed from the very first week. By mid-January, the Dentist began referring patients out for procedures to be completed at specialists' offices, which were part of his job description to perform himself. The Director discussed this with the Dentist, who stated it was in the patient's best interest to refer them out. INTER-/INTRAPERSONAL RELATIONSHIPS AND COMMUNICATION Dialogue from the Dental Director included conversations such as: "Can you tell me why we are referring this patient out instead of having you perform the services?" to which the Dentist would reply, "I'm not comfortable doing this so we are referring them out for their own best interest." To which the Dental Director queried, "But this was the agreed upon scope of your capabilities which you indicated you were willing and able to perform at your job interview with us. This is becoming a habit, soon to be protocol, that patients are being referred out for services that we are advertising that we are able to perform here. Our financial viability depends on the service mix we have marketed to patients. We can't afford to not perform these advertised services. How are we to be financially self-sustaining if we cannot perform the services we advertised that you agreed to perform?" To which the Dentist would reply, "I'm not doing them. The specialists are going to do them. I'm not comfortable, and I don't care about your bottom line. I didn't sign up to work this hard for so little money. You're not a clinician, therefore, you shouldn't even be questioning what I will and will not perform and that's that." This was usually followed by the Dentist meeting with the Medical Director and Health Center Director indicating he was unhappy answering to a non-clinician and performing services that were not in the patient's best interest. The Health Center Director would then call the Dental Director upstairs and state the Dentist's concern for not being clinically questioned. It became apparent to the Dental Director that the Dentist was undermining the chain of command and requested the Health Center Director send the Dentist back down to resolve the issues at hand with the Dental Director, according to the organizational chart and protocols, to which the Health Center Director stated there was always an "open door policy" for staff to share concerns. February brought the "Grand Opening," including a ribbon-breaking ceremony from the President of the University. Media articles and photos were distributed on campus and in the surrounding community. The demand for services by patients grew even faster. Revenues (and their successful collections) from dental services provided became apparent immediately and were extremely attractive to the Health Center Director. The financial success of the Dental Clinic, while a great reflection of the experience of the Dental Clinic Director, became an even bigger reflection of success of the leadership of the Health Center Director. The immediate profitability of the Dental Clinic, unheard of in public university settings, became coveted by the Leadership Team as a shining new model of a private practice business model in a public bureaucratic university. The Dental Director received significant accolades for the success of the Dental Clinic from all attendees including the Health Center Director and President. TEAM DYNAMICS AND STRESS IN THE WORKPLACE While the operational aspects of the Dental Clinic were streamlined, efficient, and profitable, the underlying personality clashes and unwillingness to adhere to job descriptions and job responsibilities were exacerbated by the increasing demand and became very unmanageable. The Dental Assistants, Dentist, and Dental Hygienist complained of working much harder than they were hired to do. Their expectation was to work less in a public setting for less money but to enjoy a higher quality of life due to reduced stress and work hours. The immediate and continually growing demand for services negated that. Typical responses from clinical staff members to seeing urgent care patients who walked in without appointments, swollen or in pain, consisted of "Another patient? I took a cut in pay to come work here, not to work harder for less money. That's the third extra patient put on the schedule today plus our regular full schedule. I really don't want to work this hard or this fast paced for such little pay." To which the Dental Director would reply, "That's true, you do make less salary, but your 6 weeks of paid time off and fully funded retirement plan combined equal what you made in the private sector, and you do get to leave every day at 5 p.m.that's a plus, right?! Besides, lots of demand from patients equals job security, which is rare in this economy." Clinical staff members then rolled their eyes, stated "whatever," and walked away while the Dental Director thanked them for seeing another patient not originally scheduled. The Financial Counselor required more information for billing and patient accounts than the clinical staff was willing to provide, causing tension between both groups. The Office Assistant, not used to working a busy front desk on her own, made daily, consistent errors that caused extra work for the Financial Assistant and Director to resolve. In addition, as the errors were numerous and daily, the Office Assistant would frequently lie to avoid being blamed. The Financial Counselor did not receive needed clinical information and had to correct administrative errors in addition to her growing job responsibilities. She became increasingly frustrated and expressed that to all staff members early on in an abrasive fashion. "I shouldn't have to fix your mistakes every day and I'm tired of doing your work on top of mine," was frequently stated to the Office Assistant by the Financial Counselor. Daily conversations included "Where is the insurance information for this patient and why hasn't it been verified yet?" to which the reply was "I'm very busy, the phones are ringing off the wall and I didn't get to it yet. I'm not perfect, you know." This abrasive communication added to the staff division and conflict. The Director played a dual role of managing the successful operations of the facility while resolving staff conflict, coaxing the clinical staff to adhere to their hired responsibilities, coaching the Office Assistant on job performance and skill improvement, and discussing more successful communication strategies for the Financial Counselor to use to build stronger relationships with the rest of the staff. ORGANIZATIONAL LEADERSHIP Biweekly leadership meetings with the Dental Director and Health Center Director included status updates on the Dentist's inability to work toward a resolution and goals with the Health Center Director vacillating back and forth between "Don't let him walk all over you. Enforce your goals and motivate him to change," and "I told you not to question him or make him feel uncomfortable so why is this still an issue?" Attempts by the Dental Director to involve Human Resources' conflict resolution services were denied by the Health Center Director. By March, with the schedule consistently full, the Dentist stopped communicating with the Director and referred out all patients needing more than fillings and crowns, to specialists. When confronted, the Dentist advised the Director that he was working much harder than anticipated for less money than desired, regardless of job descriptions. The Director reminded the Dentist of his terms of hiring and job description that was a needed component of financial sustainability and viability. As the Dental Clinic Director tried numerous approaches to reopen communications, the Dentist refused and submitted a letter of resignation to the Health Center Director stating his inability to "work with that woman" (the Dental Clinic Director). The Health Center Director was simultaneously being congratulated on the successes of the new Dental Clinic and confronted with the aforementioned issues. He then made a decision and informed the Dentist only that he would split the lines of leadership in the Dental Clinic. More specifically, he unilaterally changed the organizational chart so that the Dentist and the clinical staff reported directly to the Medical Director while circumnavigating the Dental Director. In addition, to keep the Dentist from resigning, the Health Center Director promoted the Dentist to Clinical Leadership of the clinical staff. This removed the clinical staff from the locus of authority of the Dental Clinic Director. None of the changes to the organization chart or the job descriptions for the Dentist or Dental Clinic Director were submitted to the Human Resources Department. The Health Center Director advised all staff that they were welcome to come to his office to resolve issues but no one was to discuss anything with the HR department on campus. WORKPLACE COMMUNICATION The Dental Director was informed of the policy change and organizational chart change after the Dentist agreed to the terms and rescinded his letter of resignation. She protested the change internally and behind closed doors to no avail. In addition, the Executive Leadership Team was not informed of the changes nor were they discussed during Executive Leadership Meetings, nor documented in minutes. No documentation was submitted to the Human Resources Department. Changes to the job descriptions were hand written by the Health Center Director and initialed. Neither the Dentist nor the Dental Director was required to sign any new job descriptions. While the Dental Clinic Director objected to this new policy change, warning of a greater division within the Dental Clinic with the potential for greater staff conflict and divisiveness, the Health Center Director advised her to improve her leadership skills and team building skills to avoid having a "program in jeopardy." He then signed her up for leadership classes through the Human Resources Department with a warning to learn much and say little. LEADERSHIP STYLES AND ORGANIZATIONAL POLITICS The division in leadership, along with the different leadership styles of both the Dentist and Dental Director, continued to create conflict among the staff. The Dentist avoided confrontation with the clinical staff, did not address any issues with them, and fostered a low key, "less is more" work ethic. Speaking only to the Director when necessary, the Dentist informed all clinical staff they were no longer supervised by the Director. The Health Center Director allowed the Dentist and clinical staff to have an "open door policy" which circumnavigated chains of command on the organizational chart. The Financial Counselor and the clinical staff continued to have conflicts as the level of attention to detail diminished with regard to clinical standards and documentation needed by the Financial Counselor to handle patient finances, present treatment options, and submit insurance claims with clinical narratives. After complaining to the Dental Clinic Director about the lack of details from the Office Assistant and the clinical staff, the Financial Counselor grew increasingly frustrated by the Director's inability to resolve the issues. The clinical staff as well as the Office Assistant aligned themselves with the Dentist as his casual leadership style was preferred. The Dentist, as clinical leadership, did not resolve issues and continued to avoid confrontation. He became friends and "colleagues" with those aligned with him. As a team, the clinical staff routinely advised the Office Assistant to reschedule patients to loosen up the schedule. CHANGE MANAGEMENT Increasingly frustrated, the Dental Clinic Director requested weekly management meetings with the Dentist in an attempt to unify the newly split leadership team, which the Dentist refused to attend. The Director then implemented team building workshops, which the clinical staff did not want to participate in. The Director then completed a 3- month leadership excellence series of workshops to improve on leadership skills. The Health Center Director advised the Dental Director to apologize to all dental staff members in an effort to "throw out the olive branch," which she did under protest to the Health Center Director. Throughout June, July, and August, the Health Center Director scheduled a series of meetings with the entire Dental Clinic staff and excluded the Dental Clinic Director from the meetings. In an effort to establish where the problems existed, the four meetings were attended by all full time Dental Clinic employees except the Director. In many of the meetings, volatility and hostility ensued as the Financial Counselor expressed dissatisfaction with the lack of leadership, lack of accountability, lack of team morale, and lack of help from all staff members. As a result of one particularly heated discussion, the Financial Counselor received a written reprimand, by the Health Center Director, which she appealed but lost. The Health Center Director advised all dental staff that if they could not begin to work harmoniously, they would all be terminated, the Dental Clinic closed, and only certain personnel would be "invited to reapply" for positions after a complete structural reorganization. ORGANIZATIONAL CHANGE AND RESTRUCTURING By November, the Dentist recommended a reorganization of the Dental Clinic to allow more profitability to generate while utilizing clinical staff members in different capacities. The Health Center Director accepted the recommendation, informed the Dental Director of the procedural changes. The Dental Director informed the Health Center Director the new procedural changes violated the state's legal statutes for "delegatable duties" that Dentists must perform themselves and warned against adverse actions from the Board of Dentistry. Proceeding against the Dental Director's warning, the Dental Clinic was reorganized for additional and enhanced profit maximization. THE FIRST YEAR: GROWTH, PROFITABILITY, AND OUTCOMES From the outside, financially and operationally, the first year of operations at the Southern University Dental Clinic was highly successful. The size of the staff doubled to accommodate the demand for services. Over 3,500 patients were seen, with revenue of over $625,000 earned. The collections ratio was over 93%. The patient satisfactory surveys reported over 93% satisfaction rate for services performed, oral health education provided, and overall quality of customer service given. The schedule was consistently booked 3 weeks out and cancellations were rare. The revenues generated and fees collected surpassed the initial estimates by over 200%. In short, the Dental Clinic illustrated the successful blending of private practice business systems in a public university could indeed exist and be profitable and efficient. From the inside, however, the unresolved staff conflict, division of the administrative and clinical departments, different leadership styles of the Director and Dentist, and lack of trust in all levels of leadership, had a significant impact on the staffing of the Dental Clinic. At the end of the first year, the original Dentist resigned, the founding Director's position was eliminated along with the founding Director, both the Financial Counselor and one Dental Assistant went out on medical leave and never returned to their positions. Other part-time staff positions were eliminated. Three months later, employee satisfaction surveys from the Health Center employees reported an overall lack of trust in the Health Center Director, who then lost authority over three additional departments. However, he continued to exercise authority over the Dental Clinic even though he knew little about dentistry and was never on site. No leadership was hired to oversee the Dental Clinic, dissention continued, while efficiency dropped dramatically along with the capability to keep up with demand for services. The positions that were vacant were not approved to be filled, as revenue collected from patients at the Dental Clinic dropped dramatically with insurance billing 90 days behind schedule. Without a Financial Counselor, revenue collection was not addressed, leaving the Dental Clinic chronically under-staffed and overworked. This negatively impacted patient satisfaction levels as the business model, without leadership, failed to operate efficiently or profitably. Six months into the second year of operations, the Health Center Director suddenly and hurriedly resigned. By the time the announcement of his resignation was made public (2 days later), his office was cleaned out, and he was gone. No documentation was sent to the Human Resources Department throughout the first year except the recommendation to eliminate the position of the Dental Director and save cost of the salary and benefits. The Executive Leadership Team was not informed of the decision to eliminate the Dental Director's position until the day after the Director was eliminated. No performance evaluations were completed nor were allowed to be completed on any dental staff member by the Dental Director, per the Health Center Director's decision. The revised organization chart and meeting minutes were documented and kept internally with the Health Center Director. They were never made available to either Human Resources or to the Executive Leadership Team.

Questions

1. If you were the Dental Director, how would you have handled the Dentist's resignation attempt 3 months after the clinic opening and the subsequent empowerment of the Dentist as clinical leadership? What steps would you have taken to minimize the organizational decline of the Dental Clinic?

2. How did the organizational culture created by the Health Center Director impact both interpersonal and intrapersonal relationships and conflict management issues in the first year of operations?

3. What were the pivotal turning points or decisions leading to the Dental Clinic's performance decline at the end of the first year and beginning of the second year?