Chapter OneBasic Mental Health Care Management Principles
This chapter is intended to provide an overview of management responsibilities, whereas the later chapters provide specific techniques and identify the skills needed to provide effective management.
Business management principles in mental health care are no different than other businesses; there are vendors and there are consumers. Some clinics prosper, while others remain stagnant or go out of business. Some develop a positive reputation, while others do not. Although there are no guarantees, there are sound business practices that increase one's chance of success.
A keen knowledge of both the consumer and the vendor must be mastered to remain competitive. A typical midsize mental health clinic does not hire a business manager, due to financial restraints. This duty usually falls upon others who also have clinical duties. Even if a business-oriented manager is hired, there are several mental health clinical skills associated with the position in which clinical training and experience are needed.
Mental health care is becoming more of a business in which professional peers and referral sources are also competitors (in a business sense). The price of trying to compete for business increases the cost of staying in business and decreases the time available to treat clients. Without it, however, a clinic can lose its competitive edge. Plus, without appropriate business skills, the quality of services can decline due to the effects of poor management. Thus, any mental health service provider who has any inkling of becoming a clinical supervisor, director, or manager should receive management training either formally or informally.
With the rise of competition for mental health consumers, one cannot avoid the decision whether to be competitive. Ignoring competition only leads to decreased business. Imagine two retail stores, located on the same block, who sell similar products. Store A's philosophy is, "It has always been our policy to make a 40 percent profit and to only sell articles that are made in this state. That's the way we've always done it, and that's the way we'll always do it." Store B's philosophy is, "If we want to grow and be competitive we will make a profit of 35 percent and we will advertise letting everyone know that our customers will have a greater variety of choices and we sell for less." It is likely that Store B will make a little less money per sale, and have more advertising costs, but the volume of business will more than make up for it. Store A might keep its loyal customer base due to its exclusive product line, but could also go out of business due to not keeping up with the market. Likewise, clinics must know their competition and make ongoing decisions based on market changes.
HOW DO CLINICS BECOME COMPETITIVE?
The answer is as simple or complicated as monitoring prices and services. Consumers want the best quality product for the least possible price. Maintaining this balance maintains one's competitive edge. Clinics that charge too low a price, or pay excessive salaries or commissions, will likely go out of business in a relatively brief period of time. Likewise, if they provide the utmost in high-quality services, their expenses could be quite high. For example, in today's professional sports the ratio of quality to price has made it very difficult for team owners. The team's consumers (those who attend the games and purchase team products) want the team to sign the best players-with contracts in the multimillion dollar range-but they do not want to pay a high price for tickets. A team with mediocre players might have low-price tickets, but there might not be much demand (low ticket sales) due to a losing season. A delicate balance of what can be afforded versus what can be charged is difficult. In mental health, a clinic does not receive more money from third-party payers for their high-end players (seasoned therapists), although there is typically a rate difference between masters and doctoral level therapists. But, seasoned clinicians typically demand a higher salary, and rightfully deserve it. Thus, when a clinic cannot afford high-salaried employees, it must increase its quality of care by other means (see Chapter 2, Customer Service).
Studebaker automobile dealers are no longer in business as Studebaker dealers. They either want out of business or changed brands. Mental health clinics that hold on to outmoded services and business practices must either expand the services they provide or face a downward spiral in business. Mental health consumers are not different from consumers for other businesses. I frequently receive phone calls from prospective clients asking questions such as the prices of services, time frames, location, and payment options. Such questions are remarkably similar to those asked in retail situations. Thus, an effective manager monitors client questions posed to the receptionist-and any others who deal with the consumers-to help the clinic become more desirable or competitive in those areas. This is comparable to a retail store that does not sell a certain product, but due to numerous client requests begins stocking the product, and thus makes a profit. This is not to suggest immediately hiring therapists who specialize in fad treatments or therapies, but does suggest keeping up with market needs for business survival.
At this point in time, the typical model of mental health care management training for students is not through academic training, but through observation of the management practices where they receive their clinical training. The quality of this experience is proportionate to the managerial abilities of their supervisor. If the supervisor is ill-trained or not business oriented, the supervisee will perpetuate the incompetence. If they happen to learn from a business-oriented model, they might do quite well, if they incorporate what they learned.
A small mental health private practice usually has about three to five employees, including one administrative person and a few therapists. The business portion of the practice involves answering the phone, setting up appointments, paying bills, and collecting fees. Many clinics can sustain themselves at this level, but they may or may not grow to be a competitive force.
The larger the clinic, the more a business-like model is needed. Larger clinics have a better chance of receiving the more lucrative contracts. However, due to the increased number of services available, these contract providers impose additional requirements on the clinic to protect their clients and investment. For example, some larger contracts require clinic accreditation or medical personnel on staff. The accrediting process involves disclosure of some very specific policies and procedures. Thus, a larger clinic is much more accountable to outside sources than a small private practice. Terms such as policies and procedures handbooks, business plans, fiscal management, and utilization review committees are likely foreign to a small clinic, but are part of the everyday lingo in larger clinics.
THREE NECESSARY SKILLS FOR EFFECTIVE CLINIC MANAGEMENT
Historically, we have assumed that the same skills employed in counseling are sufficient for management. Indeed, some of these skills transfer. For example, much of a therapist's training involves people skills, crisis management, and assertiveness. But, are these skills sufficient to manage a clinic? Several additional, specific managerial skills are needed, which are not part of clinical training. Just as a good business manager without clinical training may not be effective in a clinical setting, a good clinician may be unprepared for managerial duties without appropriate training.
Some therapists easily transition into management, while others are ineffective, no matter how effective they may be as a therapist. Clearly, the skills of therapy are necessary, but not sufficient, for management skills. The combination of at least three global skills is necessary for the therapist/manager. These include therapeutic skills, administrative skills, and relational skills. Clinical skills are needed to understand the vision of the clinic, supervise therapists, review charts, hire appropriate clinical staff, and evaluate the services of the clinic. Administrative skills are needed to organize, plan, manage, budget, market, and make the business and personnel decisions necessary for the clinic to function. Relational skills are extremely important to maintain a cohesive group, communicate, and lead a group of divergent people. Any two of these skills is not sufficient without the third.
The model of managerial training, just as in clinical skills, requires training, supervision, and experience. Many a therapist's financial downfall has been to purchase an established clinic before acquiring any managerial experience.
Mental health care providers face the additional challenge of not wanting to appear to the public as a competitive business. They do not have the luxury of certain retail stores who make advertising claims such as, "We slash the competitor's prices." No one thinks anything about these claims other than as a part of a marketing scheme for a retail business. Or, when an advertising slogan such as "You'd be crazy not to shop here" is heard, people might even think it's humorous. However, if a mental health clinic made such claims, it would likely be viewed as money-grubbing, tacky, providing low-quality services, and clearly not very professional. A high standard is clearly required in the marketing of mental health services.
Not every business decision in mental health treatment can be competitive or have a profit motive. For example, providing a certain percentage of free or low-cost services for the disadvantaged is not only an ethical practice, but it is also expected. Such a practice also allows clients, the public, and clinicians to realize the compassionate, altruistic side of the business, and reinforces the public's typically high perception of mental health therapists. The concept of a competitive clinic, to some therapists, might seem like a paradox.
As mentioned previously, mental health clinic management involves three primary skills, clinical management, and business management. Deficits in any of these areas shortchanges the clinic. The remainder of this book provides training in these areas, whereas this chapter discusses general principles. The remaining chapters also provide specific examples of needed managerial clinical and business skills.
For the sake of communication the title of the person who manages the clinic will be referred to in this text as the clinic director/ manager. In very large clinics, these might be two separate positions.
A mental health clinic director/manager is typically a seasoned therapist experienced in therapy, mental health crises, documentation, upgrading professional credentials, professional presentations, staff training, dealing with ethical issues, the ups and downs of being a therapist, and both supervising and being supervised. Although this person may have little initial experience in managing the administrative aspects of a clinic, there should be a solid track record of complying with both clinical and administrative procedures required by the clinic and the mental health field.
A therapist who cuts corners, provides poor documentation, constantly complains and degrades the clinic, or is passive-aggressive is not a good candidate for management. This does not suggest that a manager must be a "yes-person," but it does mean that the person should not be antiauthoritarian or a clinic policy-breaker. A therapist who has a history of poor compliance with administrative procedures likely does not understand the importance of those procedures and will not suddenly become an administrative role model. Thus, if a potential clinic manager is being promoted from out of the ranks, this person, besides being a seasoned therapist, should have a strong history of following the rules that he or she will later oversee.
A clinical director/manager has several clinical management duties. Whether these duties are accomplished through various committees, clinical administrative staff (mid-management), or directly by the clinic director/manager, this person is ultimately responsible for the quality of clinical care at the clinic. Simply assigning senior therapists the task of supervising novice therapists is not sufficient. Minimally, the senior therapists should report to the director/manager for supervision and case management. In smaller clinics the clinic director might provide the clinical supervision.
Case management is clearly more than simply signing off cases. It also provides an opportunity for therapists to grow professionally by discussing their viewpoint and listening to different perspectives about their client's concerns. The supervisor brings additional insight and challenges through extensive experience. Case management duties help the manager/clinic director to learn the strengths and weakness of the clinic's therapists, and provide direction to aid in clinic and client growth. In case management I ask the supervisee to respond to the following types of questions.
Reviewing charts is different from clinical supervision. It is typically called utilization review (UR) by third parties, involving reviewing the documentation in the charts of therapists at the clinic. Once again, the larger the clinic, the higher the chance that this process will be performed by a UR committee, directed by the clinic director/manager.
Reviewing charts is not necessarily a difficult process-the skill is in the knowledge of what to review, providing accurate feedback, and teaching specific skills to therapists to increase the quality of their work. Some of the main responsibilities of the clinic director/manager are to protect the clinic from unethical practices, provide medically necessary services, be accountable for clinical procedures, meet accreditation standards, and any other actions that could occur under his or her direction. Each of these actions is designed to ultimately fit the client's best interest. Thus, this person must be an expert in clinical accountability standards.
Duties, such as keeping up with changes, staff training, and a careful review of charts, are part of the job description. A clinic director/ manager without these skills leaves the clinic vulnerable to consequences such as substandard services to clients, an unsuccessful audit, and possible payback of funds collected.
Perhaps one of the biggest issues therapists have is record keeping. They may have been taught a different system, or no system, at the various clinics where they previously worked. Very few were taught such skills in graduate school. Thus, the clinic director/ manager is a supervisor, a teacher, and a mentor, and is responsible for the results of those who are supervised.
The clinic director/manager is responsible for staff training, credentialing, and development. Moderate and large size clinics routinely conduct staff training to help develop new competencies in their therapists. It is not uncommon to hold monthly staff meetings in which a portion of the meeting involves staff training. Topics such as therapeutic techniques, crisis management, safety procedures, compliance guidelines, and much more are covered. Either outside speakers or clinicians at the clinic provide the training.
Established clinics have credentialing guidelines. That is, there are established policies and procedures used to determine which therapeutic procedures may be practiced by each therapist. Typically the guidelines are based on training, experience, and supervision. New therapists must be credentialed within the clinic for each procedure and client demographic (e.g., age group, type of therapy, level of impairment, diagnosis categories). Established therapists present evidence of current training, experience, and supervision to add to their credentials. Once again, the credentialing process might be conducted by the clinic director/manager or via a committee, with final approval by the clinic director/manager.