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Engagement: A Core Strategy

Years ago my favorite TV show and favorite scene was Star Trek with Captain Picard at the helm looking out into space when, in his commanding British voice would launch the Enterprise on its journey by saying, “Engage”.  There was something special about the Star Ship Enterprise having the entire crew, warp engines, and flight deck ready to engage in interstellar travel.  Everyone poised, prepared, and ready.  One common goal:  “To go where no man has gone before”.  Then whoosh, they were gone.

Max forwarded me an interesting article from the Gallup Management Journal called “The Gallup Q12”.  The Q 12 stands for 12 questions that, in this case, identify the “engagement quotient” of their employees.  This engagement index slots people into one of three categories:

  • Engaged employees work with passion and feel a profound connection to their company.  They drive innovation and move the organization forward.
  • Not-Engaged employees are essentially “checked out.”  They are sleepwalking through their workday.  They are putting in time, but not enough energy or passion into their work.
  • Actively Disengaged employees aren’t just unhappy at work; they’re busy acting out their unhappiness.  Every day, these workers undermine what their engaged co-workers accomplish.


The results of the average engagement index are:

Engaged employees-33%
Not-engaged employees-49%
Actively Disengaged-18%

In other words, 67% of the workforce is either underperforming or actively undermining their work.

Below you will find the 12 questions that Gallup Management uses to create “Feedback for Real”.

The Q12 Index

1. Do you know what is expected of you at work?

2. Do you have the materials and equipment to do your work right?

3. At work, do you have the opportunity to do what you do best every day?

4. In the last seven days, have you received recognition or praise for doing good work?

5. Does your supervisor, or someone at work, seem to care about you as a person?

6. Is there someone at work who encourages your development?

7. At work, do your opinions seem to count?

8. Does the mission/purpose of your company make you feel your job is important?

9. Are your associates (fellow employees) committed to doing quality work?

10. Do you have a best friend at work?

11. In the last six months, has someone at work talked to you about your progress?

12. In the last year, have you had opportunities to learn and grow?

Read these and see how you do.  The answers should be YES to every question.

If you have been reading our articles over the last few years, you know how we have stressed that one of the top three reasons doctors fail to perform at the level we know they are capable of is dysfunction of their team.  Most practices have a group working in the same practice, not a team.  We have repeatedly asked you guys to go out and purchase “The 5 Dysfunctions of a Team” by Patrick Lencioni.  This short, incredibly useful book spells out how to identify and transform your group into a team.  While they do not use the term “engaged”, they describe how to eliminate the group dysfunctions in order to create a functional team (engaged employees).  If you have not purchased it yet please do so ASAP.

In another great book you should purchase, Rick Warren describes the dynamics of “The Purpose Driven Church”.  He became famous for a book entitled “The Purpose Driven Life”, but his first book, five years earlier, is probably the best business book I have read.  Just substitute “Practice” for “Church” and you will be amazed at the clarity of purpose he describes for any business.  It lends great insight into the strategies of growth and success.  Similar to the statistics described by Gallup, Warren describes his congregation in this way:  33% are core to the church (Practice), they come every day the church is open, never miss an opportunity to volunteer and support the church.  They are the Sunday School teachers, the doers of the Word, not just the hearers.  They put feet to the “vision” of the Pastor (Leader or Doctor).  The second third are great members, they attend church but are not as fully engaged as the core group that walks the talk and owns the vision.  The last third move in and out and are not really part of the ground swell he considers essential to the growth and outreach of the church.  While this is a Christian book, I can’t recommend it enough to everyone.  It does not proselytize but describes the struggles in vision casting, creating systems, and mobilizing an “engaged” group of members through systems and leadership.

If you think about it, your practice needs to understand that employee engagement is a force that drives profitable outcomes.  The engaged employees are more productive employees, more profitable, more customerfocused, safer, and more likely to not leave your practice for greener pastures.  In my practice we were able to break the average statistics of 33% engaged (or core employees) and went to over 70%.  I truly believe that the systems, tactics, reviews, and encouragement that we employed dramatically moved us from the average to world class.  Engaging employees requires a yearround focus on behavior changing processes and systems to anticipate and respond to the needs of your practice.

Once you institute the proper strategy, you must create consequences or “interventions” to drive accountability.  Lack of consequences creates an air of seeing the doctor “allowing” some action or attitude that is negative for the team.  This can happen from putting out daily fires or just a lack of systems or confrontational tolerance, but you cannot afford to send a message of inconsistence that basically says:  What you allow, you encourage.   Failure to act and create consequences empowers others to also act out and fail to meet the requirements of your systems and team.

Consider this:  The staff will not be motivated and “engaged” if the doctor is not.  You, the doctor, needs to re-read those Q12 questions and substitute your own name.  We find too many doctors that are the problem.  Leadership filters down from the top, not up from the bottom.  The person you need to work on first is yourself.  You cannot expect from others what you are not willing to do yourself.  Get engaged.

Let’s take one more perspective.  Summit has built an entire management structure around the fundamentals of a Purpose driven, Doctor led, Staff owned practice model.  We engage the team by creating an ownership mentality when it comes to the practice, systems, and staffing.

Every practice goes through a cycle of growth, plateau, slow down, and sell out.  The time varies from doctor to doctor.  The trick is to stimulate growth while preserving core (purpose).  In looking at more than a thousand practices, a trend has developed.  Every practice will hit a plateau at a certain dollar amount per month (usually about the $50,000/month level).  The practices that break through this barrier have one thing in common: They create a synergistic effect by utilizing participative management and involving their teams to create a feeling of ownership (Engagement) in the practice.  They consult their teams on major decisions.   The practice numbers are shared with the staff to encourage a team effort in order to increase productivity while pushing the overhead down.  They share the wealth through a well thought out bonus plan.  When a well-run practice does better, the team is paid more.  This synergism allows 5 staff members to produce more than a 10 staff member office.  In my practice the staff hired the staff.  They even had final say on whom I brought in as partners.  I have found that staff, and women in general, are more gifted in assessing an applicant’s abilities and understanding the dynamics of adding this person to the mix of an already great team.  I used my staff to compensate for my inadequacies in hiring the right person.  The average stay of an employee in my office was 14.5 years.  Many were there over 25 years.  This one fact accounts for a vast majority of the success in my practice.  A staff owned practice or, as Gallup would say, engaged employees, will exhibit the following:

  • Creates high communication.  Lack of communication is the major cause of system break down.  Consensus building and success in execution of systems can only occur with a high level of communication.
  • Has alignment of vision.  This is the “purpose” of your practice in motion.
  • Allows participative leadership.  This creates the synergistic effect of a small number of staff succeeding where other practices need twice as many people to get to the same level.  It is kind of the lean and mean approach.  We all know our jobs, and purpose.  We have each other’s backs.  We know what has to be done and no one leaves till everyone finishes.  It is the essence of “team” thinking and action.  We are no longer a group pulling in different directions.  We are united in purpose, and the patients can see how well we work to serve them.
  • Must have shared responsibility.  With any job there are consequences.  Each staff person knows the game and the score.  They help control the schedule to be more productive.  They lower the overhead.  They understand that the bonus is merely a way to share the profits for a job well done.  In the best practices, the doctor, during a busy schedule, is just a pair of hands.  Just another staff member doing their job.  Often times the staff directs the doctor without consult to maximize the day’s productivity.  A team effort for a team reward.
  • Is always future focused.  If you have high communication, participative leadership with shared responsibility and a commitment to the purpose of the practice, you will have a staff that focuses on the future.  The stress level will drop.  You will have a selfmanaged team.  They will come to you with solutions to problems rather than being the problem.  They will suggest strategies and continuing education to maximize the potential of the office and team.  We will have created an atmosphere of self-starters that understand this is no longer a job but a profession.  That I no longer have an hourly wage, but an unlimited earning potential.  That I am a valued member of a team united for a common purpose.


Lencioni’s book “The 5 Dysfunctions of a Team” referenced earlier best summarizes the results of a well run, functioning team.

  • They trust one another.
  • They engage in unfiltered conflict around ideas.
  • They commit to decisions and plans of action.
  • They hold one another accountable for delivering against those plans.
  • They focus on the achievement of collective results.


(Don’t miss the opportunity to read any of Patrick’s books.  Each one deals with areas of management.)

The opposite is also true.  In a seminar given by Patrick Wahl, DMD, he described workplace chaos as:

  • Failure to give credit.
  • Failure to correct grievances.
  • Failure to encourage.
  • Criticizing in front of others.
  • Failure to ask employees their opinion.


As we step from philosophy of leadership and management of a team to the actual day to day “rubber meets the road” application, please keep one thing in mind: You will be recruiting your staff from a pool of “as is” applicants.  Remember the blue light specials at K-Mart.  The announcement would be made that there is a table below the blue light with special discounts and pricing.  When you arrived at the table and looked at the products for sale you would notice a sign that warned that these items have small defects, deficiencies, and are sold “as is”.  It was a buyer beware statement:  Great prices, but buy at your own risk.  People are a lot like the items on that table.  Each and every one of us is sold as is, warts and all.  There are no perfect staff applicants.  In fact there is a common misconception about whom you should hire.  I never looked for super stars.  They always seemed to play for themselves.  Not really a team player.  One should always hire for attitude and train for skill. Always look for enthusiasm and people skills because you cannot teach this.  Add perfect systems and you can’t lose.  Systems are creatable and eliminate personalities from the process to ensure a consistent result.  Systems make procedures reproducible with any staff.  I’m fond of saying “I could teach anyone to suck spit”, but I need someone who is a great communicator, who shows compassion and caring to make the patient show up, pay for treatment, and refer everyone they know.   Remember:  Always hire for attitude and train for skill.  The final misconception is:  Always hire staff with lots of experience.  I have had great staff with experience but the opposite is also true.  Some of the worst hires I have made were people with 10 years of experience.  The problem is they want to do it the way they did in the previous office.  They are difficult to retrain.  They always seem to resort to poor habits learned from a lifetime of bad training or systems.  Some of the best people are found from different professions that would fall under the broad category of “consumer driven businesses”.  I always found waitresses to be great assistants.  They had great personalities (they had 30 seconds to make a good impression to secure a great tip), and they multitasked well.  As a waitress, they would hear the ice settle in a glass and without looking would bring out the water or iced tea moments later, while still being attentive to food service at another table.  Bank tellers, while paid very little, have good personalities, deal with people, and dot the i’s and cross the t’s to balance their drawer at the end of the day.  They make great front desk people.   Hope you get the idea.  Think out of the box to assemble a great Team.  One last thing:  There will come a time when you will have to “free up some ones future” (fire them).  You either have the right people who are in need of training or your have the wrong people and they need to be replaced.  You must make that decision.  Training an employee well and having them leave the practice is not as expensive as not training them and having them stay.

Put another way:

1. You have to get the wrong people off the bus.

2. You have to get the right people on the bus.

3. You have to get the right people on the bus and in the right seat.

4. And finally, you have to drive the bus.  You are responsible for the direction and destination of your practice (bus).

Because of the “staff owned” model and my propensity to delegate in such a way as to encourage a self-managed team, many of the daily problems most doctors face simply disappear.  The basics must still be there.   You need a wellwritten office manual.  It should, from a legal standpoint, cover all HR concerns along with rules, regulations, and job descriptions.  This manual should also close with a binding arbitration agreement to prevent frivolous lawsuits.  It should also be noted that every office manual is never finished.  It is constantly updated as jobs change and challenges appear.  If there is a problem that is new and you have to address it, then it should be added to the manual.  In this litigious society it is truly a “lawsuit lottery” with HR suits leading the way.  The office manual is your first line of defense and is also your staff’s code of conduct.  It will remove the ambiguity from the daily activities of your practice.

We take the time to document and train our staff.  In an office where the staff makes the decisions on hiring and firing, it takes little or no time to train them.   The staff always seems to attract and hire the best person for the job.  In fact, in 30 years I only had one employee that I had to fire.  Remember to update your training manuals and job descriptions.  It is not the employee’s fault if they are not trained and monitored correctly.  No one takes a position to do a poor job.  As I said before:  You either have the right people who are in need of training or you have the wrong people and they need to be replaced.  It is no longer good enough to have good employees.  You must have the very best team you can put together.  Waiting to retrain someone or fire them is the worst management decision you can make.  Act as soon as you discover a problem.

Every one in the office has a graph representing their performance.  This graph measures the one or two things that make that position important.  As an example, the hygienists keep a graph showing their individual production on a weekly basis, the number of soft tissue patients they start, and the number of crowns they present.  If you think about it, if they excelled in only these three areas you would have a great hygiene department.  The Hawthorne Effect says:  What gets measured gets done.  Decide what should be measured at each position, and begin today.  While you can get the numbers from the computer, do not use the computer to generate the graphs.  Make each person update his/her own graph(s) by hand and post it in the staff area for all to see.  As long as the graph is going up, things are good and there is no need to confront the staff member on how to better accomplish their job.  If it goes down, act quickly to find out why and help them turn it around.  This should be done in such a way as to promote consensus of purpose with no condemnation. We are all working together to take the practice to the next level.

When it comes to an actual day of work, everything comes into play.  There are large practices and smaller ones.  The most common office structure of one doctor, one assistant, one hygienist and one front desk person is the easiest to manage.  No passing the buck.  Everyone knows their job, and everyone understands that if they don’t do it, it won’t get done.  The office is physically small which makes it easier for the doctor to keep tabs on what is going on.  Change this formula and you are now faced with delegating more tasks and depending on others to follow thru without your direct supervision.

My office was a 9 hygienist practice with 4 doctors and 15 staff members open six days a week and producing millions of dollars a year with a 50% overhead.  This is the other extreme:  A corporate practice with a team leader or business administrator and a lot of bodies running around all week long.  Strangely enough, the core realities of a Purpose driven, Doctor led, the Staff owned model never changed.  With the increase of people and facility size we had team leaders for the front desk, hygiene department, and clinical staff.  This allowed me to monitor these areas without having to micromanage each position.  Each staff member still kept a graph of the couple of things most important to their jobs.  The leaders intercepted potential problems before they could grow and brought concerns from their areas to me to make a final decision on.  Problems were dealt with immediately and put to rest.   We never used a staff meeting as just a “problem solving” gathering.  We never delayed dealing with problem areas until a formal meeting.  Staff meetings were reserved for improving our systems and strategic planning.  In most cases, problems were put to rest the day we became aware of them.  The staff, through their feeling of ownership and purpose, had the authority to handle most things that arose.  We always had a written policy to guarantee the patients satisfaction (it is usually against the law to warranty a result, but not the perception of satisfaction by the patient).  We either do it over or return their money.  In the rare instance when patient got upset at us, we still earned their respect by honoring our warranty and making it right.  This is the service state of mind.  We always looked at the lifetime value of the patient and their families rather than the one time procedure or sale.

While our manual for practice management procedures and systems take up a 400 page volume, the important foundation of how, what, why, and when we do things is controlled by the purpose driven, doctor led, staff owned model.

Transformation does not occur instantaneously.  It takes a lot of energy and effort to initiate change, and it takes even more energy to build on that momentum.  Mark your calendars, read the books, meet with your team, and make employee engagement, or the staff owned practice, one of the top three core strategies for success.