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Practice Management

The Power of Positive Reinforcement

by Mark Opperman, CVPM
    Good job!

    I recently consulted for a very frustrated practice owner. He had just given all his employees their annual raise. As usual, he had not tied the raises to performance reviews or length of service—if an employee had been employed during the year, he or she received a raise. The owner had been certain that, after getting a raise, everyone would be happy, and their performance would improve. However, some employees were still coming in late, making repeated mistakes, and just didn’t seem to care. At the very least, the owner had expected that overall staff morale would improve, but it had not. He was confused.

    When VMC does a practice management consultation, we send out questionnaires with postage-paid return envelopes to get team members’ opinions and feedback regarding the practice. These questionnaires ask some very specific questions and some general ones. The responses are always interesting and informative, but we see one comment over and over again: “The practice owner or manager is quick to find fault and slow to praise.” It is the most common complaint we hear—employees do not feel appreciated.

    Positive reinforcement is relatively easy. A simple pat on the back, “thank you,” or “you did a great job” goes a long way to make your employees feel appreciated. Yet, if it is so easy, why do we fail to do it? Often, the answer is that we are simply too busy. Caught up in our own lives and responsibilities, we just don’t think about it. Even when we know how important it is and really want to give positive reinforcement to employees, sometimes we forget. On the other hand, sometimes a lack of positive reinforcement is intentional. Perhaps we truly feel that our team is not doing a good job. Maybe we’re even a little mad at them. So we take our feelings out on the team by not reinforcing them or correcting their work or behavior. Either way, the results are the same: demotivated employees and a poor working environment. A raise is not going to fix this problem.

    Can you motivate your employees? Good question. The answer is “no.” You cannot motivate anyone to do anything they don’t want to do. What you can do is create an environment in which employees want to excel at their job and end up exceeding your expectations.

    Consider this: at what point in an employee’s term of employment is he or she most motivated? The answer: on his or her first day. Newly hired employees are usually enthusiastic, happy, and excited, and they want to do everything and anything. Then what happens? We chip away at their motivation until they are unhappy or simply do not care anymore. How can we avoid this downward spiral?

    The Keys to Positive Reinforcement

    For positive reinforcement to be effective, it must meet three requirements:

    • It must be immediate.
    • It must be appropriate.
    • It must be sincere.

    Let’s look at each of these key elements.

    It must be immediate. I know a practice manager who kept track of all the good things employees did during the year and then “dumped” them on the employees during their annual reviews. The manager was surprised that the employees did not seem to appreciate this. In fact, many employees would say they didn’t remember the situation or action and wondered why the manager had waited until their evaluation to acknowledge it. The sooner an employee receives positive reinforcement, the better. The positive reinforcement can be in the form of a small reward, such as a gift card, little present, or time off, or it can just be the words “you did a great job.”

    I saw an excellent example of immediate positive reinforcement during a consultation at a practice a few years ago. I arrived at the practice early, before the hospital opened. While I waited in my car in the parking lot, I saw another car pull in. A woman got out, and as she walked to the front door, she picked up some litter in the parking lot and even got a poop bag and removed some feces. While she was doing this, the practice manager arrived, and they both went inside. I then walked in and introduced myself. The manager asked if she could be excused and went into her office. She soon came back out and approached the other employee (let’s call her Julie). The manager said, “Julie, I noticed you coming into the building this morning and picking up some trash and feces in the parking lot. Thank you so much for caring about our practice and doing that. I have a little gift for you, just to show how much I appreciate your consideration.” The manager then gave Julie a Starbucks gift card. By now, all of the other receptionists were present, and they applauded Julie and gave her a pat on the back. Wow! That demonstrates what positive reinforcement is all about. For positive reinforcement to be effective, it should be as immediate as possible.

    It must be appropriate. This is one of my favorite examples of the importance of making sure that your positive reinforcement is appropriate. At a major conference one year, I presented a seminar on motivation and delegation, and I discussed positive reinforcement in great detail. When the meeting was over, one of the attendees returned to his practice to find that his hospital had been given a minor facelift. The floors had been cleaned and waxed, the outside landscaping had been worked on, and the walls in a few of the exam rooms had even been painted. Remembering my seminar and what he had just learned about positive reinforcement, he called everyone into the treatment area, expressed his joy and appreciation to everyone, gave each employee $100, and went into his office very proud of himself.  So imagine his surprise when he emerged later to find some very disgruntled and angry employees! The next thing I knew, he was on the phone yelling at me that I did not know what I was talking about.

    As it turned out, of the dozen employees employed by the practice, only six participated in the work. Giving a bonus to everyone was a slap in the face to those who did the work and reinforced the negative attitude of those who did not. So it is very important that, when you give positive reinforcement, it is appropriate. Make sure you know that the person did the work and is deserving of your praise.

    It must be sincere. Employees know when you are sincere and when they deserve recognition. The owner or manager who constantly gives praise even when it is not warranted will lose the respect of his or her employees. Positive reinforcement should be for an act that goes above and beyond, not for, as Sheila Grosdidier would say, “converting oxygen to carbon dioxide.” For example, an employee who goes to a client’s house to pick up a pet or deliver medication deserves positive reinforcement. Employees who volunteer to participate in a career day or state fair booth, go out of their way to help another employee or client, or take a special interest in a patient also deserve recognition. You should reinforce your employees for achieving a “stretch goal,” that is, something that is beyond the expected. In doing so, you set the bar for other employees to strive to exceed your expectations. An effective manager looks for opportunities to reinforce his or her team members. I think this is one of the most enjoyable aspects of personnel management.

    A good manager should strive to reinforce positive behavior whenever possible and ignore negative behavior, unless that negative behavior is so bad it has to be addressed. Your employees should be so used to hearing praise from you that when they fail to hear it, they know they have failed to meet your expectations.

    For more tips on positive reinforcement, read the article "Best Human Resources Practices for Your Practice."

    Making Positive Reinforcement Happen

    There are lots of little tricks you can use to help you remember to encourage employees. One of my favorites is to place five quarters or tokens in your left pocket. Every time you give an employee positive reinforcement, take a token out of your left pocket and place it in your right pocket. At the end of the day, you should have all five tokens in your right pocket.

    Another favorite idea is “good job bucks.” To initiate this idea, you need to design and print some good job bucks. These could be similar to Monopoly money and, for example, might have a picture of your practice on them. Each good job buck should contain the line “I am giving you a good job buck because _________,” with an empty space for the reason.

    You also need to come up with a redemption program for good job bucks. For example, maybe employees can turn in 10 good job bucks for a $20 gift card, 40 good job bucks for an $80 hospital credit, or 50 good job bucks for a day off. Be creative and involve your employees in deciding the rewards so you can find out what is important to them.

    Once everything is ready, start giving your employees a couple of blank good job bucks with their paychecks, maybe every other week. The key is that they are blank—employees must fill in the reasons and give them to each other. They cannot keep them for themselves. In this way, employees reward other employees for doing a good job. Morale will soar!

    Implementing an Incentive Program

    In my experience, employees say that the number-one thing management could do to improve their performance and longevity within any business is to conduct regular performance evaluations. Employees want to know how well they are doing and how they can improve themselves and their performance. I believe that performance evaluations should be done at least once a year. However, if annual evaluations don’t seem to provide enough motivation, VMC uses an incentive program that rewards employees based on performance evaluations and the practice’s increase in gross income. We have found this program to be amazingly effective in motivating team members.

    The incentive program uses two components—a financial component and a performance component. The financial component requires the creation of a bonus fund. Normally, the amount of the fund is 10% of the increase in gross income from one quarter of the previous year to the same quarter of the current year. As an example, say that you compare your practice’s gross income for July, August, and September of last year to the gross income for July, August, and September of this year and find that income increased by $10,000. To create your employee incentive fund, you would take 10% of that increase, or $1,000, and set it aside. Easy enough! Employees should be made aware of the amount in the fund by posting a graph each month that shows the month’s income compared with the same month of the previous year.

    The performance component calls for evaluating each employee on a quarterly  basis. You should have specific evaluation forms for each position within your practice. Each quarter, ask your employees to evaluate themselves on the appropriate form. You (the manager or owner) will also evaluate each employee, using the same form. Then, sit down with each employee and review both evaluations. This is a great opportunity to discuss employees’ performance and let them talk to you as well. At the same time, you can talk about new responsibilities or goals you would like to see the employee achieve.

    At the end of this process, evaluation forms are scored by the practice manager on a scale of 0 to 100. However, this score must be adjusted based on the number of hours the employee has worked during that quarter. So, for example, a score of 80 for a full-time employee who works 40 hours a week would remain an 80, but a score of 80 for an employee who works 20 hours a week would be converted into a 40 because the employee only works 50% of a full-time employee. Once the scores are adjusted, they are added up, and each score is divided by the total to see what percentage of the incentive fund each employee will receive.

    To illustrate this, suppose you have two employees. One employee scores 60 on the evaluation, and the other scores 40 (after adjusting for hours). If you have a bonus fund of $1000, the first employee would receive a bonus of $600 and the other would receive $400. The entire fund is divided based on each employee’s evaluation score, adjusted by the number of hours the employee worked during that quarter.

    With this incentive program, all your employees are working for the success of your practice and are rewarded when it is achieved. There is no discrimination; a kennel assistant can make just as much as a technician or manager. The program says that if you do well in your area and contribute to the success of the practice, you have just as much right to a bonus as anyone else. We have used this program in hundreds of practices, and it has been highly successful, but you do need to follow it exactly.a


    There are many ways to create an environment in which your employees will become motivated. As a practice manager or practice owner, it is your responsibility to reinforce employees and tell them how well they are doing. Remember to reinforce the positive and ignore the negative (unless the negative is so bad it has to be dealt with) and that money in the form of salary or raise is not a motivator. However, keep in mind that if you don’t pay your employees well, they may not be able to be motivated. So pay your employees fairly, incorporate some motivational techniques, and consider incorporating an employee incentive program within your practice. I am sure you will be impressed with the results.

    aFor more information on implementing an incentive program, please contact VMC at VMC@vmc-inc.com or (303) 674-8169.


    Did you know... Salary increases, corporate recognition, and praise activate our reward circuitry similar to the activation experienced by an animal that receives a treat or has captured a meal. Read More

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