POLICIES AND PROCEDURES MANUAL

If I could get away with it, I would throw out our policies and procedures manual and replace it with the following three sentences: First, we do the right thing. Then we worry about looking good. Then we determine how we will be paid.

As a health care provider, we regularly assume the risk that a third-party payer will refuse to pay us for services that we provided in good faith. The amount that we write-off for this reason, thankfully, is relatively small because we have developed high-quality and very effective authorization and billing procedures.

If our authorization and billing procedures were not as good as they are, I would not be able to place “doing the right thing” as priority one. A company that is plagued with collection problems must restrict services when payment is less than assured. Making sure that services will be reimbursed is a higher priority than “doing the right thing” for companies in this situation. Because we have quality authorization and billing systems that keep our write-offs to a minimum, we can provide quality services even when we do not have the opportunity to ensure reimbursement a priority.

As a health care provider that specializes in supporting people with the most serious and complex behavioral health challenges, we frequently run the risk of looking bad to others even when we are doing some of our most important work. The risks we take in this area are due to a variety of reasons including:

• Community opposition because less-informed people confuse serious and complex challenges with behaviors that present a danger to their safety and the safety of their family members.
• The need to use creative and unconventional approaches when dealing with the most serious and complex challenges.
• The higher potential for problems when dealing with the most serious and complex challenges.

Looking bad must not be confused with doing bad. Just as the appearance of good does not always indicate the presence of good, the appearance of bad does not always indicate the presence of bad. In fact, an organization like ours that is dedicated particularly to serving people with the most serious and complex challenges frequently looks bad specifically because we assume the risks associated with doing the most difficult good.

We are firmly committed to placing doing good as our first consideration even when this potentially makes us look bad. Neither we nor any other organization can afford to completely ignore appearances, however. Once a best effort at doing good is assured, we must consider how we can look good, particularly when we need to correct the appearance that we are doing bad.

If staff members individually and collectively would follow these three rules with the proper attention to the order of presentation, I am certain that the most serious problems we face would be alleviated. The reality, of course, is that some staff members do not follow the three rules and/or implement them in the wrong order.

Interestingly, our detailed policies and procedures manual does not do much to improve the proper implementation of the three rules or any of the myriad details in the manual that support these three basic principles. I make this definitive statement based on my repeated observation that the real problems in our organization and in every other organization are not a function of lack of knowledge. They are a function of lack of character. While ignorance of the rules leads to many problems, these problems are relatively small and can easily be corrected in most cases with proper supervision. When they cannot be corrected with proper supervision, this is usually an indication that there is a mismatch between the staff member and her job. Transfer to a different position or termination of employment with the organization usually are the only options in this case. Training the person in the proper procedures will have little impact if the person is not suited for the position.

Lack of character causes the big problems. Lack of character usually involves some combination of dishonesty and unscrupulousness. Of course, no policy and procedures manual can get a dishonest and unscrupulous staff member to do what is right.

So why do we have a detailed policies and procedures manual if it cannot increase the probability that we will avoid the big problems? I am sure that there are many reasons. The most obvious reason, however, is that it is required by law, regulation, and accreditation standards. For now, I will concede the need to comply by having a detailed policies and procedures manual.

HUMILITY

A humble person does not act humble. A humble person IS humble. There is no important activity that is beneath the dignity of a person with exceptional self-confidence. Humility is not about denying my achievements. It is about me not feeling too important to respond to another human being in need.

According to an ancient Jewish prayer, the Almighty King of kings is not too dignified to “sustain life with dignity, resurrect the dead with great mercy, support those who have fallen, heal the sick, free the imprisoned, and keep His promise to those who have passed on.” If He is not too dignified for these and other activities, on what basis are we?

For too many people, humility is a role that they play to garner the admiration of others. This form of “humility” is the ultimate expression of deceit and conceit and has nothing to do with real humility.

People who are really humble do not act humble. They are humble. A person who is humble recognizes that no one, not even the Almighty King of kings, is too big or too important to help someone in need.

Helping someone in need frequently can be accomplished by performing a highly respected act. Acts of this type include giving money to charity, transmitting knowledge and skills to people who need the knowledge and/or the skills, and helping an infirm person across the street. These activities are absolutely good regardless of what is received in return from the other person. They are acts of kindness and charity that do not require a significant level of humility because they do not compromise my sense of dignity in any way.

At other times, helping someone in need requires that I perform an act that seems to interfere with my dignity. Plunging a stopped-up toilet, for example, may help many people who need to use the toilet. As president of a fairly large organization, many people might believe that it is beneath my dignity to do this task myself. I disagree.

Obviously, this type of activity is not my preferred activity, and if there is someone else available to do it, I will delegate it. I delegate this task, not because it is beneath my dignity, but because I delegate all activities that I can so that I can concentrate my efforts on activities that cannot be performed by someone else. When there is no one else available to plunge the toilet, it is my job to do so. In fact, I have done this job numerous times and derived a sense of accomplishment from it.

Many people seem to think that denying one’s accomplishments is a way of being humble. Frequently, these same people believe that they are too important to plunge a toilet or some other “degrading” task. The attitude that “I am too important” speaks much more to the issue of a person’s humility that his “humble” demeanor.

As the leader of a large organization that supports people with some of the most severe and complex disorders, I have accomplished great things. Some of those great accomplishments have included changing an adult’s dirty diaper and clothes, having a very sick person with a diagnosis of profound mental retardation vomit on me multiple times as I tried to keep him calm as he suffered with a stomach flu, “transferring” a person with cerebral palsy from his wheelchair onto a toilet and back into his wheelchair, etc. Other of these great accomplishments are accomplishments that are more traditionally considered great like developing and operating more than 100 group homes for people with the most serious and complex challenges.

Am I aware that I have achieved more than most other people? Yes. Do I proudly take credit for my accomplishments with others? Yes. Have I ever been known to deny that I have accomplished great things? I do not remember this occurring. Does this mean that I am not humble? I do not think so. But if it does, I surely do not care.

GUILT

Pathological Guilt: I am guilty. There is no hope for me.
Healthy Guilt: I acted badly. I will try to act better in the future.
No Guilt: The issue of my guilt or innocence will be determined by the Almighty after I die. Until then, my job is to work hard to do the right thing. Doing the right thing involves evaluating and re-evaluating what I have done to ensure that I continue to improve.
Guilt can have a dramatic positive influence on a person’s behavior. If feelings of guilt motivate a person to improve his performance now and in the future it has performed a very valuable service.

The problem with guilt is that it incapacitates as much or more than it motivates. Feelings of guilt can be so strong and pervasive that they become a basis for a negative self-image. When this happens, the person may give up hope that he will ever be able to improve. This leads to feelings of inadequacy, hopelessness, and helplessness.

Many religions focus on guilt as a primary motivator for good. To the extent that these religions are proclaiming the will of the Almighty, who am I to argue with them? Despite this conundrum, I believe that focusing on doing good is a much better way to motivate oneself and others.

Doing good should be the guiding principle in everyone’s life. A person may be committed to do good because it is the will of the Almighty that men strive to do good. Others may be committed to do good because “It is good to be good and one must do good to be good.” I really do not care why a person makes a commitment to do good. I only care that the commitment is made.

If I focus on doing good, I need not concern myself with my prior guilt or lack thereof. The past is the past. To the extent that the Almighty wants to judge me based upon the past, that is His business. Focusing on doing good now and in the future motivates me to do what the Almighty wants at least as well as focusing on my guilt. Actually, it focuses me more directly and more proactively. (Guilt may motivate me to avoid doing bad. It is less likely to motivate me to do good.)

If I focus on doing good, I avoid focusing on doing bad. That is enough. Actually, that is everything!

OUTCOMES

The Almighty controls everything. He gave me the choice to try or not to try. If I try and succeed, the Almighty gets credit for the outcome, and I get credit for trying. If I try and fail, the Almighty takes responsibility for the outcome, and I get credit for trying. My job is to try. I will let the Almighty worry about the outcomes.

Whether an individual believes in a Superior Being or not, he must acknowledge that achieving outcomes is not completely in his hands. This is partially because there are many variables that cannot be controlled or that can be controlled only in part. It is also because there are many people competing for control in essentially every environment.

Once a person recognizes that he cannot control outcomes, there is a risk that a person will not try or will not try whole-heartedly. “Why should I try if I may fail through no fault of my own?” seems to be a common theme among people who have stopped trying. The answer to the question is simple: The purpose of trying is to increase the probability of achieving positive outcomes. I have met many people who have tried and failed many times. I have never met anyone who keeps on trying and does not achieve increased success because of these determined efforts.

Of course, trying hard and repeatedly with limited or no success is very discouraging. Feeling discouraged after working hard decreases motivation to continue to try. Failure to achieve a goal is a form of punishment that occurs naturally whenever a person fails. Behavioral psychology has shown conclusively that punishment that follows a behavior decreases the probability that the behavior will reoccur.

I find it necessary to counter this naturally occurring punishment with some self-generated positive reinforcement. When I look back and evaluate my efforts, I concentrate on the quality of the efforts, not the quality of the outcomes. I know that I do not control the outcomes. If I did not achieve the outcomes I desired, this is not necessarily an indication that I did not try appropriately. If I determine that my efforts were appropriate, I reinforce myself by acknowledging an effort well executed. I recognize that what I have tried to accomplish was commendable regardless of whether or not I accomplished my goals.

An additional benefit of this approach is that it facilitates self-correction in the future regarding the aspects of my behavior that really count. If I determine that my efforts were less than maximally effective, I analyze what I did versus what I might have done better. Improving my efforts will increase the probability that the outcomes I try to achieve are realized in the future.

Even as I recognize that I might have done better in the past, I make an effort to self-reinforce my past efforts. True, I could have done better, but there were many aspects of what I tried to do that were very positive. I deserve credit for these efforts regardless of the outcomes and regardless of what I might have done better. Whether or not others will provide positive reinforcement for my efforts, I will do so myself.

The knowledge that my prior experiences have provided feedback that will improve my future efforts is additional positive reinforcement for those past efforts. An important goal of all efforts should be improvement of self. If I learn from my failures to achieve, I have improved myself. Thus, I have succeeded, at least in part. If I force myself to learn from every failure, I never fail completely.

PROBLEMS

Understanding the problem is half of the solution. Putting aside personal considerations, at least temporarily, is half of understanding the problem.

The most common decision-making error I observe is trying to find a solution without really understanding the problem. The problem with problems is that they are like icebergs. The tip is the only part that is observable.

If we design a solution that is based on our knowledge of the observable portion of the problem, the solution may make the problem worse even if it addresses the issues observed. Usually, a solution based on the limited observable aspects of a problem does not even address the issues observed.

I find that I need to stop premature discussion of potential solutions almost all the time. Most problems are not real emergencies and do not need immediate solutions. Even when a problem is an emergency, the emergency component of the problem should be addressed by the staff members who are directly responsible for the environment in which the emergency occurred. This is usually a rapid response that is almost reflexive in nature and is not based on any discussion of the problem. If a patient displays dangerous behaviors, for example, staff members who are directly responsible for the patient’s care must redirect the patient and ensure the safety of all. Staff members must be sufficiently trained so that this can be accomplished without any discussion of the problem, let alone the solution. Emergency procedures must be in place prior to the occurrence of emergencies. They must be implemented immediately and have little or nothing to do with solving the problem.

Once the emergency is over, a solution can be sought. This must start with a discussion of the many aspects of the problem until the problem is reasonably defined. Once the problem is reasonably defined, the solution may be self-evident. If it is not, the solution can be developed in a comprehensive manner by the decision-makers.

Reasonable definition of the problem is not as simple as it sounds. The parts of the problem that are not directly observable constitute the majority of the problem. Determining what these non-observable factors are can be difficult. Even more difficult is looking at the problem objectively. Problems almost always arouse strong emotions. Strong emotions always color what we see. They color what we cannot see even more. What we do not see, for example, is almost always more frightening than what we do see. Putting aside personal feelings and considering the problem objectively is a prerequisite for properly analyzing the problem.