As a Physical Therapist, Amy spent years in school learning best practices for patient care and how to put the patient first. Like so many technically skilled clinicians, she advanced to a leadership role. Spending 20+ years in operational leadership, she had an epiphany: Putting the customer first isn’t the path to success or fulfillment. Rather, the most successful organizations and practices put their people first – and exceptional customer care, profitability, and effectiveness naturally followed.
- What is a People First approach?
- A People First approach is a mindset/philosophy of leadership and not a series of tactics.
- What are the foundational building blocks/attributes of a People First Approach?
- Until recently there has been a focus on Patient First. How is this different?
- How have changes within the structure of healthcare employment and delivery over the last 10 years forced managers/owners to rethink how we lead people?
- Are generational differences impacting the way we need to lead and manage?
- How did Covid impact the way we should lead/manage?
- What practical steps can private practice owners take immediately to start along the path of a People First approach?
- What are the consequences of not changing to an employee-first mindset? How have we seen this?
[00:02] AD: Alliance Physical Therapy partners in Agile Virtual Physical Therapy proudly present Agile and Me, a Physical Therapy Leadership podcast devised to help emerging and experienced therapy leaders learn more about various topics relevant to outpatient therapy services.
[00:20 ] Richard: Welcome back to Agile and me of PT Leadership Podcast series. Today I'm really excited to welcome Amy Lafka. Welcome, Amy.
[00:28 ] Amy: Thank you.
[00:30 ] Richard: Great. Amy is an expert in her field. Amy is actually a physical therapist herself. I think it's been a couple of decades, hasn't it? But you don't look over more than 21, Amy, so congratulations. You held various leadership positions, but more recently she moved into consulting, and specifically consulting, really for organizational design and promoting kind of development of teams and culture within PT practices. As well as being a PT, you have, I believe, an MBA and also some additional specific training to kind of leadership this.
[01:15 ] Amy: Absolutely, yes.
[01:17 ] Richard: Excellent. Well, welcome. We're excited to chat with you. I think the first thing that I'd like to ask is you written a book, as I see in the background, People First. What is the People first approach? Because we've adopted as an organization and it's something relatively new to me, but what exactly is it?
[01:44 ] Amy: So the idea behind People First is that we needed to flip the traditional model of the way that we look at our organization a little bit on its head, really. So often I was raised in healthcare and through school, we were trained patient first, patient first. And that is absolutely true when you are the clinician directly working with a patient, when you're the front desk person connecting with that patient. Absolutely true. But what I learned the hard way and became the foundation for my work is that as a leader and as an organization, if our focus is on that patient first, but we're not the ones directly touching the patient, then we're missing all of the people in between. US as a CEO, us as a leader, us as an organization and that patient. And so what People First really does is accentuate the fact that you have your best and brightest commodity, is actually your people. And the people you support are the number one priority for your organization because if you put your people first, they'll have the energy, the engagement, they'll feel empowered to put the patient first. But you can't do that remotely away from the patient. And if you try to, that means you're running over your people, which is going to inhibit your ability to be successful in the long run. So the People first approach is just recognizing that our employees are our greatest asset, our team is what's going to drive our success. And if we put our team first, we will then have success. On the other side of that, you.
[03:32 ] Richard: Bring up the really good point, I believe, with regards to this shift from patient first to people first. And I've been qualified a couple of years and certainly within my two thirds of my career, it was always pushed that it was the patient. It was the patient and everything that we were taught and the focus and the culture was the patient. And as you say, it's not necessarily we dismiss that or believe that that isn't important. It's the fact that you have to take our care of the staff member, don't you? To be able to successfully achieve the patient first.
[04:20 ] Amy: Exactly.
[04:21 ] Richard: And I think what I don't understand really is why it took me so long to really work that out. And I just kind of got ingrained with that patient first mentality, certainly very prevalent within hospitals. I think they gravitated a little bit, haven't they? More recently away from that and understanding the employee focus. But still it is very much patient first centric, even within hospitals, isn't it?
[04:48 ] Amy: Well, and think about in terms of hospitals and healthcare, when we are going through our training, we are being trained to put our patient first because we are the front line putting our patient first. And then you look at the IHI, which has a huge quality initiative. And their quality initiative was focused on serving the entire population. It was focused on cost reduction. And so there was this triple aim that for decades has driven the approach that healthcare took with their triple aim. And in 2014 an article was written by two physicians about shouldn't the fourth aim be the fact that we can achieve our first three aims if we take good care of our people? And the IHI has never officially adopted that as their fourth aim. But it's true. If we want to accomplish cost reduction, patient satisfaction, quality indicators, we can't do that without the people on our team. And so you can't have a model of healthcare that ignores the delivery system.
[06:00 ] Richard: Yes. Very recently, what we have done really based on this understanding that there is this additional component that surrounds the employee, we started using the Employee Net Promoter Score, which is only one facet of people first or concept within this larger mindset, which we'll talk about. But I recognize that if I don't do well with the Employee Net Promoter Score, then how can I ever do well with the patient Net Promoter Score? And I don't know if you've come across that or whether you think that's a valid kind of process.
[06:46 ] Amy: Absolutely. And I love the way that you said it. You can't be successful with your NPS scores from your patient experience if your employee experience is not positive. I experienced that personally myself. Just recently. I had to get a medical test and it was just a phenomenal experience. And I said to the radiology tech, I said everyone here seems just so happy. And she's like, oh my gosh, it's a phenomenal place to work. And then I asked her what makes it a phenomenal place to work? And she went through the different elements. But what I found interesting was when I left, I couldn't wait to give them a ten out of ten. I made sure I had her name correctly spelled so that I could write that positive review. If she had come out and said, you're here. It's a test. I had a bad day. I hate my boss. It would have been a very different experience for me as a patient. And that's what we failed to recognize for so long.
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[08:24 ] Richard: When we talk about People First, is it a mindset philosophy or is it a series of tactics or is it kind of a combination? I'd love to know a little bit more about what it is.
[08:39 ] Amy: I love this question because the answer is it is both. When we look at what the people first approach is, there's a mindset and intentions component. So I've built it as if it's a cairn, which is a stack of rocks that are going to guide you on your path. And the foundational rock is absolutely our think. And then what I like to point out is that there's two different aspects we're looking at at the same time. There's the leadership aspect and the way we design our practices. And so the leadership think is the mindset and philosophy of a leader. To say I put my people first organizationally, the think is how do we create our values, our vision, our core purpose to incorporate not only our patient but our people. So that's the foundation. And then every aspect that we go through of the people first approach includes not only that foundational mindset, but then there are very practical, tactical things that we can do both on the leadership side and on the way we design our practice. So when we think about on the leadership side, what are the practical, tactical things? It's our ability to have good self regulation of our emotions. It's our ability to be productive when we're having a conflict resolution situation. It's the ability to have critical feedback and critical feed forward delivered in a way that supports the people and that team member in front of you. And so that's the leadership aspect of People First. And then the organizational design is everything from how we design our annual performance process, how we define performance management across the life cycle of the employee. And that people first aspect starts with how we plan our selection, how we look at how we onboard, how we create inspiration and alignment to our organization, and then what we do to empower and engage our staff and all of those elements are very much tactical, process driven components.
[11:01 ] Richard: I love the concept of the can or building blocks or foundation. I often use the concept of building a house as well. A lot of kind of leadership type of principles. And building an organization, you have to have that strong foundation. And like you said, I believe it all starts with really a mission vision value that truly embeds this concept from day one. And it's ingrained from the very basics of the culture, isn't it? Because if you don't have that stated clearly and then also driven by the practice owner of the leader and they walk the walk, then the rest of the stones won't balance, will they?
[11:49 ] Amy: Absolutely. And it's interesting, I've helped several companies really refine or define their core purpose, their mission, their vision and values. And when we do this process, it creates such clarity. And I think that's one of the aspects that carries through every element of people first is creating clarity and your core purpose. Your mission is an opportunity to show your unique value proposition as an organization. But when we create mission statements that are four paragraphs long and nobody remembers what it is, it's not helpful, because I want to be able to say to any team member, I want to be able to say to myself, as the owner, here's the mission statement, and here is how my role carries out that mission statement every single day. So your front registration desk has a role that carries out the core purpose. They have a role in helping to achieve the vision. And every position in your organization has that. So that clarity around that foundational rock of think is what's going to allow everything else to happen. It's going to drive our decision.
[13:04 ] Richard: I think the other point that I've seen in organizations and actually in hospitals, although I'm not trying to bash hospitals, but when there is even a people first approach, it's not necessarily equal. So it's, well, we'll take care of the clinicians and we'll focus on the clinicians. But as it pertains to health care and care of the patient, they are very often actually a small amount of time within the episode of care or the visit duration. It's literally everyone. And you can't segment out or say, okay, people first for the clinicians, but for the rest, well, you focus on the patients or we don't need to worry about you. I just need to keep my clinicians. But that is so wrong, isn't it? At every level?
[14:00 ] Amy: Absolutely. And I think that's driven by the history of fee for service payment. And so we find this, I find this in private practices all the time that I'm working with. They value the clinician because that is their definition of profit generation. And one of the programs I'll take clients through is called the profit zone. And what it does is equalize and level out the playing field because we help people recognize that there are a team of people in your organization who generate the profit. But then there are two other components. And there are the people that support the people generating the profit and there are the people that support the processes that generate the profit. So it's challenging to say that I'm going to support my clinicians because they drive my profit. Well, if you don't have anybody that can actually do the scheduling or you don't have anybody that can send out the bills, your profit generation capability goes down. And so we want people to recognize that if we're going to view value through profit and the ability to generate profit, that there's other components of generating profit besides delivering and creating a bill.
[15:22 ] Richard: I've talked a little bit about kind of the foundation, which is kind of when you're looking at the care model as the think, tell me a little bit about what sits on that foundation and what other components.
[15:34 ] Amy: Absolutely. So the other components are say, do and grow. And the reason that these become our additional rocks is the fact that it's not only what we think as an organization, but it is what we say. And organizationally, when we're designing say, it's actually our communication strategies, it's our cadence of meetings, it's the topics we cover in our meetings, it's the way we structure all of our communication. I went into one organization, they were using Slack texting. They had a piece of paper on the refrigerator that was like their news update of the week. So they were using all these mechanisms of day and they were getting lost because there were so many places that things could get missed because there were too many places to look. So it can even be that when we think about organizational say, and then leadership say is our ability to communicate effectively, to facilitate decision making effectively, to coach, to support people. And that does come through our words. And then after we've got our words, we recognize that for leaders, the majority of our communication is nonverbal. And that's where the do comes in. Richard, you mentioned it right off the bat. When we look at someone who is going to walk the walk, that's part of the do that we're talking about for leaders and then for design and the organization, the do is all of our processes, it's all of our procedures, it's the way we run our operations. And so that's everything from selection all the way through engagement, including our onboarding processes, all of that is the organizational do. And then technically, those three rocks are enough. But if we really want to have a phenomenal people first organization and a phenomenally successful business, it's got to include growth. And as leaders, we need to not rest on our laurels. We need to be continuing to grow and develop. And as an organization, it's valuable for us to also make sure that we are growing our people. One of my mottos is grow your people to grow your business. And so that grow rock organizationally. Sure. It could include adding a new location, it could be doing a strategic plan if you've never done one before so that you are looking at your business growth model. It's also how do you design growth opportunities for your team?
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[19:09 ] Richard: In my simplistic manner and please forgive me in advance. The way I see it is first and foremost you got to understand what you want to communicate, who do you want to be, what do you have to say and then it's understanding how you say it in an effective manner and accurately and in a manner that will be heard and heard correctly. Yes, it's hard. And then once you've said it, then you've got to do it, which it's easy to oftentimes to talk about it. It's much harder to actually do it.
[19:53 ] Amy: Yeah.
[19:54 ] Richard: And then this growth component is ideally kind of the hardest part, I feel to be successful at it's hard enough for the others. And I feel that each stone requires an increasing amount of effort and input to be truly successful. Is that how you see it? Or do you see each one just as hard as the other? Or how do you picture each stone perhaps?
[20:27 ] Amy: Richard, I really appreciate that because I have not thought of it as does it get progressively harder as you go up higher on this collection of rocks? And the reason is because I think for a lot of organizations and a lot of leaders think is actually the hardest because our mindset gets wrapped up in patient first. Our organization's definition of a vision can get wrapped up in the ROI, the revenue. So I really appreciate this idea because for me it has always been once we've level set the thinking, then the other pieces will fall in line because those other pieces are actually skill set. And we know that one of the most challenging things to shift is not our skill set, I can go learn skills, but truly shifting our mindset has always been to me the hardest piece and it's the foundation. But I do see what you're saying in terms of this idea that it can get more challenging as you move up because it's going to take different skills. And so when I think about business owners, practice owners, that I've worked with, they might have had phenomenal skill set when it came to my organization is one clinic or my organization is one clinician or my organization is ten clinics, that might be their sweet spot. And for you to be able to continue to grow and continue to expand or make the business more successful in whatever mechanism you define that, it takes a different skill set. I think of one of my clients. They've got 160 employees at this point, great top line revenue, over 20 million, doing really well. And yet now they are struggling because they had this rapid growth. In four years, they went from 40 employees to 160. So they had such rapid growth, they're now trying to catch up to themselves. And that's taking a completely different skill set the CEO really struggled with. But Amy, this is what's always worked for us. So I can see that component of it gets harder over time and as you go up higher through that.
[22:56 ] Richard: So if somebody adopts the People First philosophy and tactics, I suppose the first question is, why should I? And what's the benefit? Because change is tough. Cultural change is tough. It takes a long time, a lot of effort, blood, sweat and tears. Hopefully not too much blood, but certainly sweat and tears. So I suppose if I'm a practice owner or a multi site practice owner, what's the value in kind of shifting towards this?
[23:34 ] Amy: Absolutely. So you mentioned the employee NPS score earlier, and there has been a lot of research done that for organizations and employees who are engaged in their work. We have fewer medical errors, we have increased productivity, decreased turnover, decreased absenteeism. And so there's some real financial benefits to actually being people first. And I know as private practice owners, as business owners, we do have to think of that financial element. And there's hard data that supports people first engaged employees creating a better bottom line for your organization. For example, I told you about that group that I took through the profit zone, and when their front desk realized how they actually truly support the profit production in the organization, it shifted their approach to cancel no show rate, because suddenly that's inhibiting our profit production, and I have a role in profit production. Whereas before, they weren't seeing their value in terms of that profit production. They saw their value simply as creating a warm environment for the patient. And the organization was quite comfortable with a relatively high rate of turnover when it came to your front desk. They're not that important. But then there's that financial implication of turnover. If a front desk position is making 18, who knows what it's making now? I mean, I still see people with 1215, 1820. I just had someone with 21 out in California. That turnover still has a cost to the organization, and it's going to be at least 35% of their annual salary and benefits. So from a very practical, tactical business standpoint. People first has a financial benefit and then organizationally it's going to have benefits where you are going to have higher patient satisfaction, you are going to have less drama, and we all want less drama. But if people actually are engaged in the work, it's going to decrease the level of drama in your organization.
[25:55 ] Richard: Absolutely. Now, one thing that concerned me a little bit with the people first approach was my fear regarding providing an environment that really let the employees do whatever they wanted. But that's not true, is it? Because a true people first approach still has that accountability, doesn't it? It still has expectations built into it. It still has requirements for different roles and positions, so it doesn't allow for the Wild West. So that's kind of reassuring because that's something that did worry me in the beginning. Is that something that you've kind of been asked about or talked about?
[26:52 ] Amy: I get that question all the time. Does people first mean that I can never terminate an employee who is not meeting expectations? Absolutely not. People first still might include a termination. I had someone ask me, well, everybody wants off on Friday, so does that mean I have to give everyone off on Friday? I said, well, only if your plan is to close the practice on Fridays. People first is an approach to any situation in your work environment, any conflict. There's a people first approach to that. I'll never forget when one of my clients reached out in the early days of COVID and said, amy, we're going to have to furlough people and I want to be people first here, but I cannot afford to keep everybody on the payroll. How can I be people first and let people go? And I said, you already are people first because you're asking that question. We didn't come to a decision that people first meant he was going to keep everybody on the payroll. He was still going to have to furlough people. It's the way he went about doing it. People first includes things like accountability, the difference between a traditional approach of accountability and a people first approach. And this isn't my approach per se. It comes from a lot of research, but it's being clear up front, making sure that your team members have all the information they need so they can choose to be successful in their work. And if they get to a place where they choose not to be successful in their work, then there's a mechanism to handle that in a people first way. And so every aspect is still people first, even if it's not that everybody gets off on Fridays or sure, let's just give everybody five weeks of vacation because that's what feels good to them. Engagement and satisfaction are very different things.
[28:54 ] Richard: You mentioned the word expectations and that I think a lot of organizations leaders are fearful, somewhat fearful, of setting clear expectations. But ironically, what I found is perhaps the younger generations that are entering the workforce, I found that actually, they crave to understand and know what the expectations are, more so than perhaps the older generations like myself. I'm not sure if that's just Richard or whether that's actually seen through your eyes as well, but I think we are afraid sometimes that we will upset people when we set clear expectations. But it's quite the opposite, I found. I don't know if that's what you found as well in your consulting.
[29:51 ] Amy: Absolutely. And in terms of the generations, one of the things that we have to remember is when that group of professionals or that front desk person, they're graduating high school, they're going through college, whatever it may be, their whole educational system has been built on a rubric of, here's what you need to do. Here's my grading system. Here's how you get an A. So people come out of school saying, what's the rubric for success here? How do I get an A? And somehow we've thought that, oh, if I'm too clear, they're going to say, I don't want to do that. Well, if that's their answer, I don't want you here either, because if that's not what you want to do, then we're not the right match for each other. And so I've found, interestingly, when I go into an organization and I may be going in for team dynamics, I may be going in for leadership development, whatever the reason I'm in there, one of the first things we end up doing is redesigning their key expectations. And I will never forget and this doesn't have anything to do with generations. It was two women, probably in like, mid to late career, and we were doing the key accountabilities for one of the roles, and our subject matter experts were in the room, and the one subject matter expert looked at the other and said, well, you do that, don't you? And she's like, I don't do that. You do that. No, I don't do that. And they've been there for ten years. So when we think about setting clear expectation, we're inviting the person to be successful. And when we don't share the expectations, we're ensuring that they're going to struggle. So when you think about expectation setting, it's simply setting the guardrails up. Here's what we need from you. Here's how we're going to measure it. Here's how you're going to get rewarded for that work. And the more clear we are, the better, I think. Job descriptions, I know there's HR reasons we have to have them, but I can't tell you, I went into one organization, I said, now, what job is this? And they're like, oh, you have to look at bullet number 15. And that tells you. And I'm like, oh, this is clearly front desk, or, oh, this is clearly the ATC. But the first 14 were just blah, blah, blah, blah, blah. You'll be excellent. Communicator you'll support beneficial health care. Let's get real verbs. Action oriented expectation. Here's your bucket, here's how important it is, here's how we're going to measure success. And that one document becomes your entire performance management tool.
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[33:15 ] Richard: We kind of mentioned, or I mentioned, the idea of generational differences, probably because I'm in my latter third of my career now and perhaps a little introspective. What motivated me, or what motivates me is very different than I believe gen Y, Z, whichever. And I don't necessarily I wasn't brought up my education and jobs when I was younger. Never focused already on people first. It was whatever the task was. We had multiple people apply for the position to do this task. You're here to do the task. If you don't like it, then we'll find somebody else and tough you're forgotten. So it's almost like a number. And I worked in Factory for ten years as well, and the first thing we asked was your clock number, even before I asked them what their name was very often. But that just doesn't cut it anymore, does it? It's a different world. And I assume I'm correct in saying different younger generations, different generational, more recent generational groups do have different expectations of the workplace and their employer. And how I was treated just wouldn't cut it now, would it? And it definitely is more now of a people first mentality, correct?
[34:43 ] Amy: Absolutely. And it's interesting when you mentioned what motivates people. And one of the assessment tools that I use is called Driving Forces Motivators. And thankfully the company that I use has been in business for 40 years, so they have longitudinal studies and we can see over the generation whether or not the true underlying motivation for people has shifted. We're not finding a shift in what truly motivates people. There's a certain percent of the population that's always been motivated by the ability to learn new things for the sake of learning. There's always been people who are motivated by the ROI, by serving others. But what is different is the way we have to execute the work environment to pull that out of people. I work with one accounting firm and they love to tell the story about how one of the partners used to not let the men come into the meetings if they weren't wearing leather sold shoes. And so they use this as the story of kids today have it so easy. I couldn't go into the meeting if I didn't have on. Leather, sold shoes. And then I'll say to them, so was that right or was that just the way it was? And they said, It was totally wrong. I said, Then why would we want to perpetuate that? And so I think there is a real difference today in the generation, not in terms of what motivates them, but exactly what you said, Richard. What their expectations are at work. They have an expectation that it is a team sport and they want things to be more about that connection, more about integrating work and life. Because we've all learned work life balance doesn't actually exist. So it's how do I integrate the two so that I'm happy in both? And the reality is that when we came out of World War II, we were in a very much hierarchy, authoritarian style. The majority of people had been through the military service, so when they came out of military service, that's exactly the way they treated their employees. That top down hierarchy over the years that has faded away. And the leadership styles that are successful now are not that top down authoritarian because people's expectation of the work is different.
[37:15 ] Richard: I wasn't brought up during the war. I'm not quite that old.
[37:19 ] Amy: I did not mean that at all, Richard. Although cascading effect.
[37:26 ] Richard: Having said that, my parents were actually teenagers during the war. So I think that has kind of bled over to me slightly, but hopefully not too much. If we pivot a little bit. From a practical perspective, if I'm a client director or a leader of a group of clinicians or rehab department, where do I start with regards to the people? First, I'm listening to the podcast. Some new concept to me. Probably in the back of my mind I've been kind of going down this path anyway. I'd hope that I'd be going down this path based on the needs of the employees. But from a practical perspective, what can they do if they know that they've got to move towards this?
[38:14 ] Amy: I think there are two things that you can do right off the bat that aren't incredibly time consuming but have a lot of bang for their buck. The first thing is get clarity around the key expectation. So you may have job description, but what you actually want to do is pull out your job descriptions, line them up with your mission statement, and then meet with your team and say, for example, if your performance eval has a meets, exceeds, does not meets, I want definition attached to that. So what does it mean to meet expectation? A lot of practices that I work with will actually convert instead to a percent demonstration of a behavior. So if we expect you to do this, what percent of the time do you demonstrate achievement? And what percent of time is considered an A, B or what have you? So the first thing to do is really get clear on your expectations, those action verbs of what we want you to do and then how we're going to measure success. And once you've got that, share it with the entire team right away. The second thing that you can implement right away is setting up one on one quarterly meetings with everyone in your team. So if you are the practice owner and I will never forget one of the first practices I worked with. She had two employees and she said to me, amy, why would we ever do a quarterly sit down? I see them every single day. And I said, yes, but do you talk about the expectations, their performance, what's going well for them? She's like, no, but I see them all the time. So if there was an issue, they'd let me know. We implemented quarterly meetings one on one with her and each of her two employees. And she came away from the first one and said, you will not believe what I learned. Exactly. And now it becomes more of that partnership that people are looking for. It's a dialogue, it's a conversation. So I think quarterlies is something that you can quickly implement and carry through and it's going to build energy over time. And when I look at quarterlies, I've had people say, well, Amy, I am a multi site coordinator. I have five locations. I said, okay, then that's five quarterlies you need to do because your site managers are going to do the quarterly for their team member. And so it's a cascading effect. And when we think about quarterlies, it's just a couple of questions. Who should we recognize this quarter? What's going well for you? What are you challenged by? What are your goals? How are we doing on helping you meet them? Let's review the core expectations and make sure you're on track for the end of the year. That's it. And those are two very simple ones to implement right off the bat.
[41:10 ] Richard: That's great. The time is always against us. There's so many questions, so little time. I think to finish. A common question I ask all my guests, really is any words of wisdom? Really based on what we've talked about and raised points, raised, what would you leave the listeners with? Anything? Final comments, shall we, sir?
[41:40 ] Amy: I think the first is to be patient with yourself. If this people first mindset is something that you're wrapping your head around and we are talking about that, think rock, be patient, but don't give up on the concept. Really start to become an observer of when do I immediately go to, well, this is my need as a leader or a business owner versus looking and saying, okay, have I been clear enough with my key accountabilities? Because I will tell you, every organization I work with, the owner will say, oh, everybody knows what they're supposed to do. And then when we do this process, it's eye opening. So recognize that by moving into a People First approach. We're not saying that you're not doing good work as the leader, as the owner, we're simply saying there's an opportunity for more.
[42:36 ] Richard: If any private practice owner would like to reach out to you, get more information about your consulting services, or continue the conversation, how might they get hold of you, Amy?
[42:50 ] Amy: The easiest way is to simply email me. It's Amy@karencs.com. I'm sure we can find a way to put that into some marketing piece for that, but A-M-Y at C-A-I-R-N-C s.com, you can feel free to call me 570-617-7836. Clearly, Richard and I could talk about this stuff all day long, and my goal is just to help as many people as possible. So get in touch with me with one of those ways, and we can certainly have a conversation about what might be most helpful for anyone's practice.
[43:26 ] Richard: Personally, Amy, I want to thank you for all your help to guide myself, my organization, my team with the People First approach. We are fully committed to it and traveling along the journey. We certainly haven't built all the stones on top of each other yet, but we're trying our best. So thank you for everything you do, and it's been great talking to you.
[43:53 ] Amy: Thank you very much, and I appreciate the journey that you're on, and thank you.
Podcast Transcript
[00:02] AD: Alliance Physical Therapy partners in Agile Virtual Physical Therapy proudly present Agile and Me, a Physical Therapy Leadership podcast devised to help emerging and experienced therapy leaders learn more about various topics relevant to outpatient therapy services.
[00:20 ] Richard: Welcome back to Agile and me of PT Leadership Podcast series. Today I'm really excited to welcome Amy Lafka. Welcome, Amy.
[00:28 ] Amy: Thank you.
[00:30 ] Richard: Great. Amy is an expert in her field. Amy is actually a physical therapist herself. I think it's been a couple of decades, hasn't it? But you don't look over more than 21, Amy, so congratulations. You held various leadership positions, but more recently she moved into consulting, and specifically consulting, really for organizational design and promoting kind of development of teams and culture within PT practices. As well as being a PT, you have, I believe, an MBA and also some additional specific training to kind of leadership this.
[01:15 ] Amy: Absolutely, yes.
[01:17 ] Richard: Excellent. Well, welcome. We're excited to chat with you. I think the first thing that I'd like to ask is you written a book, as I see in the background, People First. What is the People first approach? Because we've adopted as an organization and it's something relatively new to me, but what exactly is it?
[01:44 ] Amy: So the idea behind People First is that we needed to flip the traditional model of the way that we look at our organization a little bit on its head, really. So often I was raised in healthcare and through school, we were trained patient first, patient first. And that is absolutely true when you are the clinician directly working with a patient, when you're the front desk person connecting with that patient. Absolutely true. But what I learned the hard way and became the foundation for my work is that as a leader and as an organization, if our focus is on that patient first, but we're not the ones directly touching the patient, then we're missing all of the people in between. US as a CEO, us as a leader, us as an organization and that patient. And so what People First really does is accentuate the fact that you have your best and brightest commodity, is actually your people. And the people you support are the number one priority for your organization because if you put your people first, they'll have the energy, the engagement, they'll feel empowered to put the patient first. But you can't do that remotely away from the patient. And if you try to, that means you're running over your people, which is going to inhibit your ability to be successful in the long run. So the People first approach is just recognizing that our employees are our greatest asset, our team is what's going to drive our success. And if we put our team first, we will then have success. On the other side of that, you.
[03:32 ] Richard: Bring up the really good point, I believe, with regards to this shift from patient first to people first. And I've been qualified a couple of years and certainly within my two thirds of my career, it was always pushed that it was the patient. It was the patient and everything that we were taught and the focus and the culture was the patient. And as you say, it's not necessarily we dismiss that or believe that that isn't important. It's the fact that you have to take our care of the staff member, don't you? To be able to successfully achieve the patient first.
[04:20 ] Amy: Exactly.
[04:21 ] Richard: And I think what I don't understand really is why it took me so long to really work that out. And I just kind of got ingrained with that patient first mentality, certainly very prevalent within hospitals. I think they gravitated a little bit, haven't they? More recently away from that and understanding the employee focus. But still it is very much patient first centric, even within hospitals, isn't it?
[04:48 ] Amy: Well, and think about in terms of hospitals and healthcare, when we are going through our training, we are being trained to put our patient first because we are the front line putting our patient first. And then you look at the IHI, which has a huge quality initiative. And their quality initiative was focused on serving the entire population. It was focused on cost reduction. And so there was this triple aim that for decades has driven the approach that healthcare took with their triple aim. And in 2014 an article was written by two physicians about shouldn't the fourth aim be the fact that we can achieve our first three aims if we take good care of our people? And the IHI has never officially adopted that as their fourth aim. But it's true. If we want to accomplish cost reduction, patient satisfaction, quality indicators, we can't do that without the people on our team. And so you can't have a model of healthcare that ignores the delivery system.
[06:00 ] Richard: Yes. Very recently, what we have done really based on this understanding that there is this additional component that surrounds the employee, we started using the Employee Net Promoter Score, which is only one facet of people first or concept within this larger mindset, which we'll talk about. But I recognize that if I don't do well with the Employee Net Promoter Score, then how can I ever do well with the patient Net Promoter Score? And I don't know if you've come across that or whether you think that's a valid kind of process.
[06:46 ] Amy: Absolutely. And I love the way that you said it. You can't be successful with your NPS scores from your patient experience if your employee experience is not positive. I experienced that personally myself. Just recently. I had to get a medical test and it was just a phenomenal experience. And I said to the radiology tech, I said everyone here seems just so happy. And she's like, oh my gosh, it's a phenomenal place to work. And then I asked her what makes it a phenomenal place to work? And she went through the different elements. But what I found interesting was when I left, I couldn't wait to give them a ten out of ten. I made sure I had her name correctly spelled so that I could write that positive review. If she had come out and said, you're here. It's a test. I had a bad day. I hate my boss. It would have been a very different experience for me as a patient. And that's what we failed to recognize for so long.
[07:55] AD: At alliance, we believe that partnership means creating something greater than the sum of its parts. Our focus is finding physical therapy practices with a strong culture and thriving community and providing them with additional tools, resources and expertise to take their practice to the next level. To learn more about joining our nationwide community of outpatient physical therapy practices, visit our website@allianceptp.com.
[08:24 ] Richard: When we talk about People First, is it a mindset philosophy or is it a series of tactics or is it kind of a combination? I'd love to know a little bit more about what it is.
[08:39 ] Amy: I love this question because the answer is it is both. When we look at what the people first approach is, there's a mindset and intentions component. So I've built it as if it's a cairn, which is a stack of rocks that are going to guide you on your path. And the foundational rock is absolutely our think. And then what I like to point out is that there's two different aspects we're looking at at the same time. There's the leadership aspect and the way we design our practices. And so the leadership think is the mindset and philosophy of a leader. To say I put my people first organizationally, the think is how do we create our values, our vision, our core purpose to incorporate not only our patient but our people. So that's the foundation. And then every aspect that we go through of the people first approach includes not only that foundational mindset, but then there are very practical, tactical things that we can do both on the leadership side and on the way we design our practice. So when we think about on the leadership side, what are the practical, tactical things? It's our ability to have good self regulation of our emotions. It's our ability to be productive when we're having a conflict resolution situation. It's the ability to have critical feedback and critical feed forward delivered in a way that supports the people and that team member in front of you. And so that's the leadership aspect of People First. And then the organizational design is everything from how we design our annual performance process, how we define performance management across the life cycle of the employee. And that people first aspect starts with how we plan our selection, how we look at how we onboard, how we create inspiration and alignment to our organization, and then what we do to empower and engage our staff and all of those elements are very much tactical, process driven components.
[11:01 ] Richard: I love the concept of the can or building blocks or foundation. I often use the concept of building a house as well. A lot of kind of leadership type of principles. And building an organization, you have to have that strong foundation. And like you said, I believe it all starts with really a mission vision value that truly embeds this concept from day one. And it's ingrained from the very basics of the culture, isn't it? Because if you don't have that stated clearly and then also driven by the practice owner of the leader and they walk the walk, then the rest of the stones won't balance, will they?
[11:49 ] Amy: Absolutely. And it's interesting, I've helped several companies really refine or define their core purpose, their mission, their vision and values. And when we do this process, it creates such clarity. And I think that's one of the aspects that carries through every element of people first is creating clarity and your core purpose. Your mission is an opportunity to show your unique value proposition as an organization. But when we create mission statements that are four paragraphs long and nobody remembers what it is, it's not helpful, because I want to be able to say to any team member, I want to be able to say to myself, as the owner, here's the mission statement, and here is how my role carries out that mission statement every single day. So your front registration desk has a role that carries out the core purpose. They have a role in helping to achieve the vision. And every position in your organization has that. So that clarity around that foundational rock of think is what's going to allow everything else to happen. It's going to drive our decision.
[13:04 ] Richard: I think the other point that I've seen in organizations and actually in hospitals, although I'm not trying to bash hospitals, but when there is even a people first approach, it's not necessarily equal. So it's, well, we'll take care of the clinicians and we'll focus on the clinicians. But as it pertains to health care and care of the patient, they are very often actually a small amount of time within the episode of care or the visit duration. It's literally everyone. And you can't segment out or say, okay, people first for the clinicians, but for the rest, well, you focus on the patients or we don't need to worry about you. I just need to keep my clinicians. But that is so wrong, isn't it? At every level?
[14:00 ] Amy: Absolutely. And I think that's driven by the history of fee for service payment. And so we find this, I find this in private practices all the time that I'm working with. They value the clinician because that is their definition of profit generation. And one of the programs I'll take clients through is called the profit zone. And what it does is equalize and level out the playing field because we help people recognize that there are a team of people in your organization who generate the profit. But then there are two other components. And there are the people that support the people generating the profit and there are the people that support the processes that generate the profit. So it's challenging to say that I'm going to support my clinicians because they drive my profit. Well, if you don't have anybody that can actually do the scheduling or you don't have anybody that can send out the bills, your profit generation capability goes down. And so we want people to recognize that if we're going to view value through profit and the ability to generate profit, that there's other components of generating profit besides delivering and creating a bill.
[15:22 ] Richard: I've talked a little bit about kind of the foundation, which is kind of when you're looking at the care model as the think, tell me a little bit about what sits on that foundation and what other components.
[15:34 ] Amy: Absolutely. So the other components are say, do and grow. And the reason that these become our additional rocks is the fact that it's not only what we think as an organization, but it is what we say. And organizationally, when we're designing say, it's actually our communication strategies, it's our cadence of meetings, it's the topics we cover in our meetings, it's the way we structure all of our communication. I went into one organization, they were using Slack texting. They had a piece of paper on the refrigerator that was like their news update of the week. So they were using all these mechanisms of day and they were getting lost because there were so many places that things could get missed because there were too many places to look. So it can even be that when we think about organizational say, and then leadership say is our ability to communicate effectively, to facilitate decision making effectively, to coach, to support people. And that does come through our words. And then after we've got our words, we recognize that for leaders, the majority of our communication is nonverbal. And that's where the do comes in. Richard, you mentioned it right off the bat. When we look at someone who is going to walk the walk, that's part of the do that we're talking about for leaders and then for design and the organization, the do is all of our processes, it's all of our procedures, it's the way we run our operations. And so that's everything from selection all the way through engagement, including our onboarding processes, all of that is the organizational do. And then technically, those three rocks are enough. But if we really want to have a phenomenal people first organization and a phenomenally successful business, it's got to include growth. And as leaders, we need to not rest on our laurels. We need to be continuing to grow and develop. And as an organization, it's valuable for us to also make sure that we are growing our people. One of my mottos is grow your people to grow your business. And so that grow rock organizationally. Sure. It could include adding a new location, it could be doing a strategic plan if you've never done one before so that you are looking at your business growth model. It's also how do you design growth opportunities for your team?
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[19:09 ] Richard: In my simplistic manner and please forgive me in advance. The way I see it is first and foremost you got to understand what you want to communicate, who do you want to be, what do you have to say and then it's understanding how you say it in an effective manner and accurately and in a manner that will be heard and heard correctly. Yes, it's hard. And then once you've said it, then you've got to do it, which it's easy to oftentimes to talk about it. It's much harder to actually do it.
[19:53 ] Amy: Yeah.
[19:54 ] Richard: And then this growth component is ideally kind of the hardest part, I feel to be successful at it's hard enough for the others. And I feel that each stone requires an increasing amount of effort and input to be truly successful. Is that how you see it? Or do you see each one just as hard as the other? Or how do you picture each stone perhaps?
[20:27 ] Amy: Richard, I really appreciate that because I have not thought of it as does it get progressively harder as you go up higher on this collection of rocks? And the reason is because I think for a lot of organizations and a lot of leaders think is actually the hardest because our mindset gets wrapped up in patient first. Our organization's definition of a vision can get wrapped up in the ROI, the revenue. So I really appreciate this idea because for me it has always been once we've level set the thinking, then the other pieces will fall in line because those other pieces are actually skill set. And we know that one of the most challenging things to shift is not our skill set, I can go learn skills, but truly shifting our mindset has always been to me the hardest piece and it's the foundation. But I do see what you're saying in terms of this idea that it can get more challenging as you move up because it's going to take different skills. And so when I think about business owners, practice owners, that I've worked with, they might have had phenomenal skill set when it came to my organization is one clinic or my organization is one clinician or my organization is ten clinics, that might be their sweet spot. And for you to be able to continue to grow and continue to expand or make the business more successful in whatever mechanism you define that, it takes a different skill set. I think of one of my clients. They've got 160 employees at this point, great top line revenue, over 20 million, doing really well. And yet now they are struggling because they had this rapid growth. In four years, they went from 40 employees to 160. So they had such rapid growth, they're now trying to catch up to themselves. And that's taking a completely different skill set the CEO really struggled with. But Amy, this is what's always worked for us. So I can see that component of it gets harder over time and as you go up higher through that.
[22:56 ] Richard: So if somebody adopts the People First philosophy and tactics, I suppose the first question is, why should I? And what's the benefit? Because change is tough. Cultural change is tough. It takes a long time, a lot of effort, blood, sweat and tears. Hopefully not too much blood, but certainly sweat and tears. So I suppose if I'm a practice owner or a multi site practice owner, what's the value in kind of shifting towards this?
[23:34 ] Amy: Absolutely. So you mentioned the employee NPS score earlier, and there has been a lot of research done that for organizations and employees who are engaged in their work. We have fewer medical errors, we have increased productivity, decreased turnover, decreased absenteeism. And so there's some real financial benefits to actually being people first. And I know as private practice owners, as business owners, we do have to think of that financial element. And there's hard data that supports people first engaged employees creating a better bottom line for your organization. For example, I told you about that group that I took through the profit zone, and when their front desk realized how they actually truly support the profit production in the organization, it shifted their approach to cancel no show rate, because suddenly that's inhibiting our profit production, and I have a role in profit production. Whereas before, they weren't seeing their value in terms of that profit production. They saw their value simply as creating a warm environment for the patient. And the organization was quite comfortable with a relatively high rate of turnover when it came to your front desk. They're not that important. But then there's that financial implication of turnover. If a front desk position is making 18, who knows what it's making now? I mean, I still see people with 1215, 1820. I just had someone with 21 out in California. That turnover still has a cost to the organization, and it's going to be at least 35% of their annual salary and benefits. So from a very practical, tactical business standpoint. People first has a financial benefit and then organizationally it's going to have benefits where you are going to have higher patient satisfaction, you are going to have less drama, and we all want less drama. But if people actually are engaged in the work, it's going to decrease the level of drama in your organization.
[25:55 ] Richard: Absolutely. Now, one thing that concerned me a little bit with the people first approach was my fear regarding providing an environment that really let the employees do whatever they wanted. But that's not true, is it? Because a true people first approach still has that accountability, doesn't it? It still has expectations built into it. It still has requirements for different roles and positions, so it doesn't allow for the Wild West. So that's kind of reassuring because that's something that did worry me in the beginning. Is that something that you've kind of been asked about or talked about?
[26:52 ] Amy: I get that question all the time. Does people first mean that I can never terminate an employee who is not meeting expectations? Absolutely not. People first still might include a termination. I had someone ask me, well, everybody wants off on Friday, so does that mean I have to give everyone off on Friday? I said, well, only if your plan is to close the practice on Fridays. People first is an approach to any situation in your work environment, any conflict. There's a people first approach to that. I'll never forget when one of my clients reached out in the early days of COVID and said, amy, we're going to have to furlough people and I want to be people first here, but I cannot afford to keep everybody on the payroll. How can I be people first and let people go? And I said, you already are people first because you're asking that question. We didn't come to a decision that people first meant he was going to keep everybody on the payroll. He was still going to have to furlough people. It's the way he went about doing it. People first includes things like accountability, the difference between a traditional approach of accountability and a people first approach. And this isn't my approach per se. It comes from a lot of research, but it's being clear up front, making sure that your team members have all the information they need so they can choose to be successful in their work. And if they get to a place where they choose not to be successful in their work, then there's a mechanism to handle that in a people first way. And so every aspect is still people first, even if it's not that everybody gets off on Fridays or sure, let's just give everybody five weeks of vacation because that's what feels good to them. Engagement and satisfaction are very different things.
[28:54 ] Richard: You mentioned the word expectations and that I think a lot of organizations leaders are fearful, somewhat fearful, of setting clear expectations. But ironically, what I found is perhaps the younger generations that are entering the workforce, I found that actually, they crave to understand and know what the expectations are, more so than perhaps the older generations like myself. I'm not sure if that's just Richard or whether that's actually seen through your eyes as well, but I think we are afraid sometimes that we will upset people when we set clear expectations. But it's quite the opposite, I found. I don't know if that's what you found as well in your consulting.
[29:51 ] Amy: Absolutely. And in terms of the generations, one of the things that we have to remember is when that group of professionals or that front desk person, they're graduating high school, they're going through college, whatever it may be, their whole educational system has been built on a rubric of, here's what you need to do. Here's my grading system. Here's how you get an A. So people come out of school saying, what's the rubric for success here? How do I get an A? And somehow we've thought that, oh, if I'm too clear, they're going to say, I don't want to do that. Well, if that's their answer, I don't want you here either, because if that's not what you want to do, then we're not the right match for each other. And so I've found, interestingly, when I go into an organization and I may be going in for team dynamics, I may be going in for leadership development, whatever the reason I'm in there, one of the first things we end up doing is redesigning their key expectations. And I will never forget and this doesn't have anything to do with generations. It was two women, probably in like, mid to late career, and we were doing the key accountabilities for one of the roles, and our subject matter experts were in the room, and the one subject matter expert looked at the other and said, well, you do that, don't you? And she's like, I don't do that. You do that. No, I don't do that. And they've been there for ten years. So when we think about setting clear expectation, we're inviting the person to be successful. And when we don't share the expectations, we're ensuring that they're going to struggle. So when you think about expectation setting, it's simply setting the guardrails up. Here's what we need from you. Here's how we're going to measure it. Here's how you're going to get rewarded for that work. And the more clear we are, the better, I think. Job descriptions, I know there's HR reasons we have to have them, but I can't tell you, I went into one organization, I said, now, what job is this? And they're like, oh, you have to look at bullet number 15. And that tells you. And I'm like, oh, this is clearly front desk, or, oh, this is clearly the ATC. But the first 14 were just blah, blah, blah, blah, blah. You'll be excellent. Communicator you'll support beneficial health care. Let's get real verbs. Action oriented expectation. Here's your bucket, here's how important it is, here's how we're going to measure success. And that one document becomes your entire performance management tool.
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[33:15 ] Richard: We kind of mentioned, or I mentioned, the idea of generational differences, probably because I'm in my latter third of my career now and perhaps a little introspective. What motivated me, or what motivates me is very different than I believe gen Y, Z, whichever. And I don't necessarily I wasn't brought up my education and jobs when I was younger. Never focused already on people first. It was whatever the task was. We had multiple people apply for the position to do this task. You're here to do the task. If you don't like it, then we'll find somebody else and tough you're forgotten. So it's almost like a number. And I worked in Factory for ten years as well, and the first thing we asked was your clock number, even before I asked them what their name was very often. But that just doesn't cut it anymore, does it? It's a different world. And I assume I'm correct in saying different younger generations, different generational, more recent generational groups do have different expectations of the workplace and their employer. And how I was treated just wouldn't cut it now, would it? And it definitely is more now of a people first mentality, correct?
[34:43 ] Amy: Absolutely. And it's interesting when you mentioned what motivates people. And one of the assessment tools that I use is called Driving Forces Motivators. And thankfully the company that I use has been in business for 40 years, so they have longitudinal studies and we can see over the generation whether or not the true underlying motivation for people has shifted. We're not finding a shift in what truly motivates people. There's a certain percent of the population that's always been motivated by the ability to learn new things for the sake of learning. There's always been people who are motivated by the ROI, by serving others. But what is different is the way we have to execute the work environment to pull that out of people. I work with one accounting firm and they love to tell the story about how one of the partners used to not let the men come into the meetings if they weren't wearing leather sold shoes. And so they use this as the story of kids today have it so easy. I couldn't go into the meeting if I didn't have on. Leather, sold shoes. And then I'll say to them, so was that right or was that just the way it was? And they said, It was totally wrong. I said, Then why would we want to perpetuate that? And so I think there is a real difference today in the generation, not in terms of what motivates them, but exactly what you said, Richard. What their expectations are at work. They have an expectation that it is a team sport and they want things to be more about that connection, more about integrating work and life. Because we've all learned work life balance doesn't actually exist. So it's how do I integrate the two so that I'm happy in both? And the reality is that when we came out of World War II, we were in a very much hierarchy, authoritarian style. The majority of people had been through the military service, so when they came out of military service, that's exactly the way they treated their employees. That top down hierarchy over the years that has faded away. And the leadership styles that are successful now are not that top down authoritarian because people's expectation of the work is different.
[37:15 ] Richard: I wasn't brought up during the war. I'm not quite that old.
[37:19 ] Amy: I did not mean that at all, Richard. Although cascading effect.
[37:26 ] Richard: Having said that, my parents were actually teenagers during the war. So I think that has kind of bled over to me slightly, but hopefully not too much. If we pivot a little bit. From a practical perspective, if I'm a client director or a leader of a group of clinicians or rehab department, where do I start with regards to the people? First, I'm listening to the podcast. Some new concept to me. Probably in the back of my mind I've been kind of going down this path anyway. I'd hope that I'd be going down this path based on the needs of the employees. But from a practical perspective, what can they do if they know that they've got to move towards this?
[38:14 ] Amy: I think there are two things that you can do right off the bat that aren't incredibly time consuming but have a lot of bang for their buck. The first thing is get clarity around the key expectation. So you may have job description, but what you actually want to do is pull out your job descriptions, line them up with your mission statement, and then meet with your team and say, for example, if your performance eval has a meets, exceeds, does not meets, I want definition attached to that. So what does it mean to meet expectation? A lot of practices that I work with will actually convert instead to a percent demonstration of a behavior. So if we expect you to do this, what percent of the time do you demonstrate achievement? And what percent of time is considered an A, B or what have you? So the first thing to do is really get clear on your expectations, those action verbs of what we want you to do and then how we're going to measure success. And once you've got that, share it with the entire team right away. The second thing that you can implement right away is setting up one on one quarterly meetings with everyone in your team. So if you are the practice owner and I will never forget one of the first practices I worked with. She had two employees and she said to me, amy, why would we ever do a quarterly sit down? I see them every single day. And I said, yes, but do you talk about the expectations, their performance, what's going well for them? She's like, no, but I see them all the time. So if there was an issue, they'd let me know. We implemented quarterly meetings one on one with her and each of her two employees. And she came away from the first one and said, you will not believe what I learned. Exactly. And now it becomes more of that partnership that people are looking for. It's a dialogue, it's a conversation. So I think quarterlies is something that you can quickly implement and carry through and it's going to build energy over time. And when I look at quarterlies, I've had people say, well, Amy, I am a multi site coordinator. I have five locations. I said, okay, then that's five quarterlies you need to do because your site managers are going to do the quarterly for their team member. And so it's a cascading effect. And when we think about quarterlies, it's just a couple of questions. Who should we recognize this quarter? What's going well for you? What are you challenged by? What are your goals? How are we doing on helping you meet them? Let's review the core expectations and make sure you're on track for the end of the year. That's it. And those are two very simple ones to implement right off the bat.
[41:10 ] Richard: That's great. The time is always against us. There's so many questions, so little time. I think to finish. A common question I ask all my guests, really is any words of wisdom? Really based on what we've talked about and raised points, raised, what would you leave the listeners with? Anything? Final comments, shall we, sir?
[41:40 ] Amy: I think the first is to be patient with yourself. If this people first mindset is something that you're wrapping your head around and we are talking about that, think rock, be patient, but don't give up on the concept. Really start to become an observer of when do I immediately go to, well, this is my need as a leader or a business owner versus looking and saying, okay, have I been clear enough with my key accountabilities? Because I will tell you, every organization I work with, the owner will say, oh, everybody knows what they're supposed to do. And then when we do this process, it's eye opening. So recognize that by moving into a People First approach. We're not saying that you're not doing good work as the leader, as the owner, we're simply saying there's an opportunity for more.
[42:36 ] Richard: If any private practice owner would like to reach out to you, get more information about your consulting services, or continue the conversation, how might they get hold of you, Amy?
[42:50 ] Amy: The easiest way is to simply email me. It's Amy@karencs.com. I'm sure we can find a way to put that into some marketing piece for that, but A-M-Y at C-A-I-R-N-C s.com, you can feel free to call me 570-617-7836. Clearly, Richard and I could talk about this stuff all day long, and my goal is just to help as many people as possible. So get in touch with me with one of those ways, and we can certainly have a conversation about what might be most helpful for anyone's practice.
[43:26 ] Richard: Personally, Amy, I want to thank you for all your help to guide myself, my organization, my team with the People First approach. We are fully committed to it and traveling along the journey. We certainly haven't built all the stones on top of each other yet, but we're trying our best. So thank you for everything you do, and it's been great talking to you.
[43:53 ] Amy: Thank you very much, and I appreciate the journey that you're on, and thank you.