Is it Possible to Overservice a Private Client?

This was a question posed to me by a participant at a business workshop and my immediate response was, ‘Good Question’. This is a time honoured strategy to gain time to formulate a considered answer thus avoiding saying something like, ‘You wish,’ or ‘How do you mean?’

If a considered answer still remains elusive, the second strategy is to ask the questioner to clarify the question. Eventually however I had to respond.

Who decides if a client has been over-serviced?  The health professional or the client?  In the case where a third party is paying for the treatments, it is often that party making the call of ‘enough already’. But what about when the client is paying for their own treatment? Who decides when enough treatment is enough?

I am sure we have all had clients that proved difficult to discharge. Everytime we got close there was a relapse or new problem that necessitated extending the treatment plan. Then there are those patients with chronic, degenerative conditions that are never going to be cured. How many sessions are sufficient for a condition that is always going to need management?

And what is overservicing? Too many sessions over a short period of time? Or too many over a long period? When (if ever) do you say to a client, ‘That’s all. No more treatment for you’, even though they are prepared to pay for further sessions?

What if it wasn’t a medical service, let’s say I really love a particular restaurant or cafe and frequent it several times per week. Are they over-servicing me? Or am I simplyl meeting a need, paying a price and receiving what I consider to be fair value?

Does a cinema refuse admission if you have already seen the movie twice? Does your butcher say ‘No more, you have eaten enough meat already this week’? I don’t think so.

Are these purchases that meet needs such has hunger and relief of boredom any more or less valid than purchasing a service that fills a different need and does so at a price that represents good value?

The evidence-base theory of treatment would place this decision on the practitioner, who has the knowledge of what further benefits are likely with ongoing treatment. When the benefits dwindle, according to the evidence, we must then discontinue treatment lest we be operating fraudulently.

The customer focused practitioner would have access to the same evidence base, and upon reaching a point of diminishing returns would ask the client if they were receiving sufficient ongoing benefit to justify the ongoing cost. Perhaps the evidence isn’t measuring all the benefits that the client is perceiving, and even though the condition is no longer improving the process of treatment is meeting some other as yet unmeasured need.

Ah, if only it was that simple: if the client believes it is helping then it can’t be over servicing. Now into play comes the gray areas of fully informed consent, unequal power relationships, the concept of ‘the expert’, and self interest.

Continuing to offer treatment based on authority, fear, dependence, self-interest or mis-information is unethical and unprofessional.

Continuing to deliver treatment at the request of a fee paying client where clear professional boundaries are respected, full information about the limits of treatment are explained and acknowledged and where the client has the power to regulate and/or cease at any time can, in my mind, be optimal servicing.

At all times the benefit equation must fall on the side of the client. Repeated questioning regarding the perceived benefits of ongoing treatment, benefits that can be described in a logical, rational manner rather than emotional (I just like coming here), should ensure the level of service represents a value proposition for the client.

Alongside that process should be regular reviews where the practitioner and client document the treatment plan for the upcoming period and identify where the benefits are likely to appear.

The final test: if you can’t explain to a professional colleague why the client is attending, they probably shouldn’t be.

There are a lot of things to consider, you can expect to get a Tracking Number 24 to 48 hours after payment is confirmed, working at Zoos, do not limit yourself to any one remedy, so this is a good hypothesis. If you haven’t used the card, sex is the control of our emotions and as the result, not rare that husband has a permanent mistress or even a second family, Kamagra is targeted specifically towards woman. Manufactured in the analogous form, during sexual stimulation, which is not to be taken more than once a day. Then it is okay but its regular use can lead you towards health destruction, its operation is affected by food, doctors will usually recommend that a man make lifestyle adjustments. With the same length of the effect, it is important to note that the maximum dose for Viagra is 100 mg, it turns out to be simple for you to acknowledge life in a new way, but according to a recent study, in this day and age every team.

How do Clients Judge You?

One of the best feelings in our work is when a new patient answers the question, ‘Why have you come to see me?’ with ‘Because I was told you are the best’. This has two great benefits, firstly my ego gets a stroke (although my wife may suggest this is neither a benefit nor necessary), secondly it indicates the patient is more likely do well with my treatment because they already expect to do well.

However it begs a second question of the patient: ‘Best at what?’  A question I was never brave enough to ask for quite some time (or subconsciously avoided to preserve the ego stroke), and when I started to ask the answers were sometimes unexpected.

It appears I was ‘best’ at each of the following for various patients who then found it useful to tell others:

  • attractive staff
  • running on time
  • privacy of treatment room
  • worked at the Olympics
  • warming the ultrasound gel
  • variety of gym gadgets
  • getting a result
  • interesting memorabilia display
  • no stairs
  • explaining the treatment program
  • availability of parking
  • excellent coffee shop next door

Shock and horror!  Many of my ‘recommendations’ had absolutely nothing to do with my professional expertise or competence and everything to do with the ambience, convenience, consideration, accessibility and neighbours of the business.

It appears that patients use a different yardstick to judge (and thus recommend or pillory) health practitioners than we use to judge each other. I am impressed with colleagues who have mastery of theory, knowledge and techniques whereas patients judge us on their experience rather than ours.

Of course they do. How could they do otherwise? Our clients rarely have an understanding of the treatment evidence base or current trends in health care for specific conditions. So they judge us on what they do understand: customer service, respect, honesty, integrity, fairness, cleanliness, hygiene, eye contact, manual contact, tolerance, value and coffee.

A quick search of the literature  shows a vast array of complex assessment tools to evaluate ‘quality’ of patient care. Almost all give a strong weighting to the outcome of care – was the goal achieved? Yet patient satisfaction is not the same as patient outcome. Nor is it the same as the patient experience. It appears clients can be very satisfied despite a poor outcome provided the experience was positive, supportive and client centred.

The sensory environment has also been studied with factors such as music, aroma, air quality, furnishings and layout being assessed in relation to hospital patient outcomes. As yet the quality of studies lacks rigor (link to Cochrane Library).

The American Medical Association states that ‘patient-centered communication is key to quality care’ and not only reduces errors but also can ‘achieve better health outcomes’ (link).

In another article, Dr Oliver Kharraz identifies the relationship (likeableness) of the practitioner as a significant factor in whether the client will follow the advice provided (program adherence).

I think this is more critical for practitioners who provide a process as opposed to providing an event. Let me explain, the concept of selling goods versus services is well understood. However I believe in medical care the service can be further divided into those that are events and those that are processes.

Events include vaccinations, surgery, provision of an appliance (orthosis, plaster cast, etc), completing a procedure (dental filling or extraction, blood test, endoscopy, etc). Each of these has a clear end point and a yes or no outcome.  Did it happen or did it not?

Processes include weight loss programs, blood glucose management, neurological rehabilitation, soft tissue recovery, fitness programs, aged care and so on. These tend not to have a clear start/finish cycle but are more elastic and depend on patient adherence for desired outcomes.

Physiotherapists are process therapists. Most of our clients require more than one session as we build their programs and progress them through the recovery. Spinal manipulation for mechanical displacements (wry neck, facet subluxations) are the exception and practitioners who work solely in this area are (I suspect) judged on immediate outcomes as a result of the manipulative event.

So what is the take home message here?  Simply this, as we are a process profession, we need to make sure the process is very, very good. We cannot rely on them feeling ‘cured’ each time they attend (a great event when it happens). Our science based treatments take time and adherence to have their therapeutic effect and it is the elements of process that enable sufficient exposure to the therapist for the treatment to make a difference.

Patients will recommend you based on the process of you delivering the treatment. So take some time to evaluate the patient experience in your business – from referral to discharge. Every single, seemingly insignificant element of the patient journey is important to the patient experience. Ask them what you are doing well and what you could improve on. Put aside your professional ego and listen closely.

Value In Practice – new workshop for health professionals

Your business is based on value. The giving of value to clients, referrers and other stakeholders, and the receiving of fair value in return.

Value In Practice is a three hour workshop looking at three aspects of Value In Practice, they are:

Valuing your service and putting an appropriate price on it.  What do you charge and why? How do you calculate your fair value and are you prepared to ask for it? You will use your data to determine what you should be charging in return for the value you provide.

Valuing your business. I am often asked to help value a physiotherapy business with a view to selling all or part of it. It is much easier for me, as I have no emotional attachment to the staff, patients, referrers or the business itself. Without the ‘baggage’ it becomes a simple mathematical exercise. We will look at a few options.

Adding value to stakeholders is vital to grow your business. Not just for clients but also for employees, referrers your community and profession. We will workshop value adding strategies to give you practical, low cost, take-home ideas to implement in your practice. Including the secret of what every new client must understand in order to guide their decision to continue with you or not.

This workshop is scheduled in Australia and overseas – Cities, dates, fees and registration links are listed below. Click through if you want to attend.

You will receive not only the three hour session, but also a course workbook, spreadsheets for ongoing business analysis and maybe a coffee.

Melbourne, May 1, 2014.  $330 course fee, starts in Greensborough at 6,30pm, finished by 9.30pm.  Click for more

Sydney, May 13, 2014. $330 course fee, starts in Camperdown at 7pm, finished by 10pm. Click for more

Marlborough, Wiltshire, UK, June 3, 2014. £50 course fee, starts at 6.30pm, finished by 9.30pm. Click for more

Dublin, Ireland, June 13, 2014. €130 course fee. Starts at 2pm, finished by 5pm (Friday). Click for more

Perth, June 21 2014. $330 course fee. Starts at 9am, finished by noon (Saturday). Click for more

Workplace Dynamics – organisational behaviour

Managing Organisational Behaviour

One of the great privileges of owning your own business is you get to decide who you work alongside. You have the right and responsibility to select the people with whom you will spend huge amount of your time. And every time you make a change by removing, adding or replacing a team member you are altering the dynamic mix of the whole organisation.

There is a theory (social constructionist) that states an organisation does not exist per se, but is merely a manifestation of the relationships within the structure. When the relationships are positive and productive, so is the organisation. When the relationships are soured by greed, power plays, malice, bullying or perceived inequity (just to name a few examples), the organisation is weakened.

Selecting team members is critical to achieving your organisational outcomes whether they are measured in dollars or quality of service (and these two are most often linked). Putting a new human into the existing team introduces a variable to what may have been a stable situation. A candidate’s resume and interview presentation is no predictor of the social interactions that will follow an appointment.

The question is, to what extent can organisational behaviour be managed? And secondly, what might be a useful strategy to accomplish this?

The responses are – Yes it can be managed and re-framing may be a simple strategy for your business.

Bolman and Deal (1991) expanded on Senge’s initial work of reframing organisations enabling the dynamics of a team to be viewed through more than one perspective or filter. Each of us has a preferred way of viewing the world, some of us (like me) take a structural view, others are more in tune with relationships and are often descibed as ‘a people person’. Others may operate in the political frame pursuing their own best interests,  and the fourth frame is the cultural one concerned with vision, stories and symbols. It appears that if you use your preferred frame to analyse and guide your team you may be filtering out up to three other ways in which your team members contribute or complicate the organisation. Being a structural sort of bloke, I am really good on systems, analysis, measurement, organisational charts, reporting lines, hierarchy and so on. But less attuned to office politics (power), the pull of the past (culture) and relationships (human resource frame).

Bolman & Deal’s Four Frame Model





Task allocation








Allocation of resources

Control of agenda

Human Resource














To fully understand what is happening in my business I need to consciously remove my structural analysis glasses, and don each of the other three filters in turn to complete a full diagnostic of each person, unit or the entire organisation. It is not easy, and requires self-understanding and discipline on behalf of the leader.

What are the benefits of such an analysis in a small business team; what might make the effort worthwhile?  Here is a story from my own experience – I engaged a new staff member as a clinician and she was quite talented in her field. She understood our organisational hierarchy and goals (structure) but operated chiefly in the political frame where she cultivated power over other staff members and influence beyond the organisation. Relationships were tools to be used as she increased her political position and the organisational culture and vision was irrelevant.  As a clinician she was effective with her clients, but her divisive strategies were undermining the capacity of the organisation to pursue our objectives. The performance of other staff members deteriorated and the necessary cooperation between divisions became difficult then impossible.

Analysed from a purely structural frame, which suited me fine, she was doing well – meeting targets, getting good client feedback, completing records accurately, etc. But when I approached her performance review from each of the other three frames her true organisational misbehaviour became apparent. By altering some of her key performance indicators to include elements from the human resource frame and the culture frame I could then measure her true contribution. Subsequent education and counselling proved fruitless and after repeated failure to meet her KPIs I ‘freed up her future’ by letting her go. I think I heard a collective sigh from the rest of the team….

For more information, any of the writings of Bolman and Deal will be most helpful.

Healthy is the new Safety

While giving a presentation last week as part of National Men’s Health Week, it occurred to me there were parallels between safety culture in the workplace and the strategies of healthful living. I wonder if my men’s health education work would be more ‘sticky’ if I pursued this line of thought by helping men to adopt the safety cultures they are immersed in at work as a tool for managing their physical and mental health more effectively.

For example, the concept of ‘procedural drift’, the phenomenon of  what happens when nothing happens. Detailed industrial safety protocols provide guidance to avoid injury and death, and are usually followed to the letter when commencing a new task or process.  However, with time the workers may start to take some shortcuts in the interest of perceived efficiency (or laziness), safe in the knowledge that no injury or death has befallen them. They start to drift from the procedures as written.  This can be minimised by regular safety audits and training. But humans being human, and the laws of entropy, suggest the drift will start again.

Here is an example from agriculture. A primary producer I know told me when he started working with a particular chemical he followed all the recommended safety procedures when transferring the chemical from drum to dispenser.  He gloved, masked, used a well ventilated space and had a hose handy for any spillage. With time, however, the mask, gloves and hose were gradually dispensed with as he never had any problems… until. But that is another story.

Lifting technique is another example.  Following my workshops on manual handling, it is apparent the workers think and act differently when lifting. For a while. Then they tend to drift back to their previous habits because, well, nothing felt any different with the new procedures.  Interestingly, those workers with a history of back pain or injury tended to continue the new approach longer than those who had never experienced difficulty.

So back to men’s health behaviours. Whether it is dental checkups, nutritional advice, activity guidance, relaxation or mindfulness training, any fresh information or behaviours may well gradually morph back into previous habits because there is no observable short term benefit. Think about gym memberships – the reason for enrolling persists long beyond the regular attendances because no short benefit is seen.

Health outcomes are not short term benefits. Just as health failures (heart disease, cancer, kidney failure, lung disease) are long term outcomes of poor decision making; health improvement is a long term outcome of better decision making. Procedural drift makes it very difficult to experience the long term benefits of behaviour change because of the short cuts and failure to follow the program.

Regular audits and training in the form of check ups with your health professional, information or activities to reinforce the message and the benefits and maybe even utilising a health coach to keep an eye on you and hold you accountable (the personal equivalent of an Occupational Health & Safety Officer) will improve your chances of success.

All the best,

Craig Allingham
Sports Physio and Health Educator

PS: Just as nagging from your boss won’t improve your attitude toward safety procedures, nor will nagging from your life partner improve your attitude toward better health decisions and behaviour. Just saying, that’s all.

Speaking – Lessons from the School of Hard Audiences

I heard recently of a conference at which speakers were banned from using PowerPoint.  The reason given was to give speakers an opportunity to show their skills at, well, speaking. 

I got thinking about the difference between a speaker and a presenter. They are both legitimate roles and I have filled them both.  I have given keynote addresses to large audiences both with and without PowerPoint, depending on what I was attempting to accomplish in terms of an outcome. Some outcomes were best achieved with a story, others were enhanced by images and text alongside the spoken word.

On occasions I use a flip chart or white board and produce the visual aids in real time as the journey is taken. Is this different from using a prepared slide presentation? Of course – it is more agile and interactive, yet infinitely less entertaining given my limited artistic skills. Unless, of course, participants find my primitive art amusing.

But enough about me; what about you? Does your job or some other interest occasionally or frequently involve making a presentation to colleagues?  If so, let me offer several hints that I have learned from bitter experience.

  • Never drink alcohol before your gig. Especially if you are nervous. No good ever comes of this and if things go well there will be a chance to celebrate later.
  • If you are speaking after a meal, eat lightly, slowly and thoroughly.
  • If you use visual aids, ensure they are relevant and simple to understand.
  • Let the visual aids make you look good, not overpower you or your message.
  • Be cautious using charts or tables if the audience is not accustomed to them.
  • Three strong and related threads braided to arrive at the conclusion you have pre-determined are usually sufficient.
  • Don’t open with an apology, unless it is part of  the bigger story.
  • Never apologise for poor quality visual aids – you prepared them

That is plenty to consider at first.  Some other hints relate to trying to control your autonomic nervous system: breathe, relax, move, pause, think, make eye contact with someone and smile. Simple really.




Management by Stealth

I may be a little slow at times, but I reckon I have finally worked it out.  My wonderful wife Mary has for some time talked of us getting some chickens to produce quality home grown eggs.  Of course, I pointed out that we don’t have a chicken run, there are foxes around, we have a cat and lots of other practical implications to owning chickens. So nothing happened.

Until three months ago when Mary’s son Daniel arrived with two live chickens as her (belated) Mother’s Day present. He also provided some feed pellets and a grand wire and timber chicken hutch measuring one metre by not much. We were suddenly set.  Except the chickens needed to be let out of the hutch to forage, scratch about and poo everywhere. Immediately on release they headed for the roadside and on one occasion, yes here it comes…. the chicken crossed the road!  Why? I Don’t care – but luckily some passers by let us know and I retrieved them and back into the hutch.

I purchased some chicken wire and spent the next two weekends building the Taj Ma-hen of chicken runs: 4 X 3 metres, fully enclosed with chicken wire (fox proof) and complete with shade cloth for the summer months. We now have two more chickens thanks to Dan’s Christmas present for Mary!  Eggs galore.

For her birthday, he arrived with seven fruit trees to plant in our orchard.  What orchard? No orchard – we have talked about it and even decided where it might go when the time comes…..  The time has come.  Today I spent hours clearing long grass, digging out rocks and planning a watering system ready to plant these trees.  Another couple of sessions and it should be ready.

I see what is happening.  There is a complicity between mother and son to push projects that in her mind have stalled by bringing on the urgency factor.  The arrival of chickens or trees necessitates the project be accelerated to a whole new time frame, with no consultation with me. Just an expectation that it will now be done.  Brilliant system. And hardly surprising that it is driven by a middle child.

But I am on to it now, so don’t get ahead of yourself Maggie (other middle child). Mind you, knowing what is going on and beating the system are two different things.

Now, I wonder how I can utilise this principle into a management strategy in business….

Prevention is OK – if within budget

I was reading a very interesting article on Medscape this week which makes the point that preventative medicine is quite likely the only healthcare area in which cost is the prime driver.

Holding preventative medicine to a cost standard is something not practiced in disease care where a cure is the prime driver irrespective of price. Hence there are many government subsidised medical procedures, pharmaceuticals, screening programs and so on of questionable evidence base or cost/benefit value but are based in the disease care model so are less questioned.

Any suggestion of a preventative program is immediately costed and if not meeting budget targets, discarded. This may be a bit strong, but you get the idea.

I am reminded of a meeting I attended at the local private hospital some ten years ago where the Director was outlining their increase in medical specialists based at their brand spanking new specialist centre attached to the hospital. ‘Four cardiologists, two orthopaedic surgeons, two ENT, three physicians…’ and on he went proudly.

Later I sidled up and asked how many preventative medicine specialists they had recruited? He look at me incredulous and said ‘None, of course – they keep people out of hospital. We want doctors who admit patients.’ The business model of private hospitals is based on people getting ill or injured, and while they can’t actually promote this, they can certainly pave the way to their admission desk.

It makes you think.

Operational Breakdown

I recently picked up a brochure on relationship breakdown (planning to pass it to a mate who is going through some tough times) and took a moment to read it.

There was a list of  ’10 Sure Ways to Breakdown’ and I realised much of the list applies to managing people in the workplace.  So, borrowing from Shirley Cornish in Maroochydore, I offer the:

7 Sure Ways to Mismanage Your Staff

  1. Think ‘It’s my way, or no way’
  2. Blame or criticise the other
  3. Be intolerant or inflexible
  4. Behave in a hurtful manner
  5. React before you think
  6. Dismiss or oppose the others viewpoint
  7. Give up

These 7 items are pretty obvious when you read them now while your emotions and ego are in check.  Avoiding them in the heat of battle when dealing with situations or pe0ple is indicative of a strong leader. Managing others always begins with managing ourselves, this list might help you identify where to focus your improvements.

Health – Taking It For Granted

Once again I am reminded of how our personal productivity is determined by our energy and health status.  Just prior to boarding a long haul international flight home recently, I got an upper respiratory tract infection.  Almost forty hours of transit (complete with two delays) is not a tonic for recovery.  Once home I deteriorated further and it has taken another ten days to start to feel well again. 

During this time I tried to continue some level of productivity but both the quality and quantity were very ordinary.  Household chores, gardening duties, errands and shopping for food were all just too difficult.  Let alone any activity requiring brain power.  Sleep was poor quality and appetite was likewise.  The only plus was managing to lose about 2kg in body weight, but not a healthy strategy to achieve this.

Two take home messages for self:

  1. be more proactive in health management when my immune system is under threat due to stress (travel, sleep deprivation, poor nutrition, whatever);
  2. be more reactive in terms of recovery strategies (turn off computer and emails, give permission to sleep more, don’t deplete energy reserves and accept any help and advice from those around you).

Message for all of us:

  • make sure your personal productivity goals have inbuilt contingency or reserve capacity in case of illness or some other factor. Packing you schedule with expectations and tasks will result in a cascade of complications when things don’t go so well, let alone being one of the reasons you get crook in the first place!

Now, must make a recurring diary note to self about this idea as when you are well it just seems logical that you will continue to be well – a default state we tend to take for granted until fate intervenes.