The Four Agreements For Clinic Leaders

We use The Four Agreements to talk about what actually changes clinic culture: the words we choose, the stories we invent, and the standards we repeat. We share real ophthalmology examples that connect emotional intelligence to clearer training, better patient communication, and less day-to-day drama. 
• why The Four Agreements fits eye care leadership better than another KPI playbook 
• being impeccable with your word with staff, doctors, patients, and yourself 
• how gossip and passive-aggressive communication erode trust 
• not taking things personally during complaints, feedback, and tense mornings 
• using empathy to understand “difficult” patient behavior 
• stopping assumptions in premium IOL conversations, dilation education, and scheduling favors 
• always doing your best without confusing it with perfection 
• building standards first with SOPs, onboarding, and consistent training 
• making it stick through journaling, team agreements, and daily reinforcement 
If you enjoyed this episode, please subscribe to the show on your podcast app and share it with someone who would value the content. I also invite you to subscribe to my HR newsletter for Eye Care leaders. You can find information about that at seasoned-advice.com. 

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Transcript

Welcome And Show Purpose

SPEAKER_00 0:01

Greetings and welcome to iCare Leadership Live. This is the podcast for iCare leaders who want to level up their leadership, create better cultures, and improve the financial results of their clinics. Now, let's join the show.

Why The Four Agreements Matter

SPEAKER_00 0:18

Well, my guest today is Elise Levine. And we have an interesting topic today. So Elise, thanks for joining me. Thanks for having me back. Yeah, I think you're my first repeat guest. Wow. Yay. Man, I'm I'm sorry in advance, I guess. No. So we came up with this topic. I think you proposed it. And I think we're kind of like-minded individuals, and it just seemed like a really cool topic. But the the topic, well, why don't you share the topic that you proposed and what made you think of this?

SPEAKER_01 0:55

Yeah, a few years back, I was very interested in the book, The Four Agreements, and I proposed a course at Academy at AOE to talk about using the four agreements in your practice. Uh, and so there was a couple of years where I shared this book and and some of the great information in it. Uh, and one of the things about you know these meetings is that they do want to not have the same curricula year after year. So it's been a couple years. So I thought that now, especially with the kinds of things you talk about, this would be a great thing for us to have a conversation about.

SPEAKER_00 1:36

Yeah, and I love the I love the idea. I have read the book. I have a copy of it right here for anyone that wants a visual uh of what it looks like. And actually he had he has another book. I'll tell you my backstory a little, and this is getting maybe personal here, is I went through uh went through a divorce several years ago. And you know, when you go through something like that, you you look for wisdom in different places, and I really found this to be a great, a great book, a very easy read, great concepts, very understandable, relatable to anyone, no matter what you know your beliefs are or or what you're where you're coming from, it's very relatable, I think. And I think it's very applicable. So yeah, why don't we go ahead and jump in?

SPEAKER_01 2:24

Sure.

SPEAKER_00 2:25

Okay, well, so the four agreements is a book by Don Miguel Ruiz, and I guess to boil it down, he's got like four four things that that you need to that you would be wise to adopt in your life, I guess. So why don't you start us off, Elise, with the first agreement and why you think this is something that ophthalmolers might want to think about.

SPEAKER_01 2:54

Yeah, so you know, this book is not your typical management, how to swim with sharks kind of book. If you think about books that you're reading about business or that somebody's recommending to you, it's a lot of KPIs, it's a lot of systems. This is really a book about self-awareness. And some of us are more self-aware than others. Some of us have come to self-awareness over the years with and through books like this. Um, and it's not like a soft skill, it's really something that you can use to help with operationalizing things in the clinic, and it makes relationships go much easier. And so when you look at this, it's really kind of like the golden rule that we hope that everybody as they were growing up was taught.

Agreement One Words And Gossip

SPEAKER_01 3:46

So the first agreement is be impeccable with your word. And that goes when we look at it from the practice standpoint, you know, be impeccable with your word with your coworkers, with your boss, if you're the boss with your subordinates, with the patients. If you can't tell the truth, people know. And especially when it comes to ophthalmology, you know, we want to be truthful about perhaps unexpected outcomes, coverage, those kinds of things. So it's very important that from a leadership standpoint that you set the tone, that everybody knows there's that term, your word is your bond, that if you set the example that everybody knows that the manager, administrator, leader is always speaking from a place of truth, it kind of helps seep into everybody else in the practice. And hopefully then you can identify really quick who your truth tellers are and call out those who may not be living this first agreement.

SPEAKER_00 4:55

You know, there's something in that that's so true, that's so true, right? One of the things that really struck me when I read this book was being impeccable with your word about yourself and how you talk about yourself to yourself. You know, so so often we say things and and we're probably you may not be aware of it, but if you really focus, you you might notice. You we say things to ourselves like, I can't do that, or why am I such an idiot, or I don't deserve this. And even if we don't say it out loud, out loud, or even say it in our head, we say it in metaphors, we say it in different ways to ourselves. Do you think that that do you think that's true?

SPEAKER_01 5:40

Absolutely. It starts with you internally. If you don't think you can run a marathon, you can't.

SPEAKER_00 5:47

Yeah, and you know, there's another thing. I'm looking at the book right now, and and he also talks about gossip. And gossip is another way of it's it's being harmful with your words, and so talking about others in a negative way or a disempowering way. Has that been something that you know you've been an administrator, you know, and gossip is just that's one of those universal things in healthcare, I think, that just happens. Have you have you seen that in your experience and the damaging effects of that?

SPEAKER_01 6:19

Oh, absolutely. And you know, passive-aggressive communication, not giving the full uh instructions to somebody and then ha-haying it when they don't do what they were supposed to do because they didn't know, even not setting, you know, expectations appropriately. If you have a new tech and this is their first job teching, and you're training them and you don't teach them how to close the room at night, how can you be mad at them the next day when you didn't set the expectation? You didn't give them an SOP that said cover the equipment, clean the tonometers, XYZ. You can't live in that space because now you're creating all kinds of angst when it was just really about telling the truth about what needed to be done. And the same thing with gossip, it just it erodes the whole structure of the practice.

SPEAKER_00 7:17

Yeah. So yeah, the whole point of of agreement one is the power is this the power of words, basically, whether it's saying it to yourself or others. So it's a great, it's a wonderful way to start the book. Second, agreement. Don't

Agreement Two Stop Taking It Personally

SPEAKER_00 7:34

take anything personally.

SPEAKER_01 7:37

Tell me about it. This is a hard one. Yeah. This this is a hard one, and it's also hard for newer people in management or leadership positions. Um, because oftentimes the you know, there's an adage that being a practice administrator is the loneliest position in the practice because the doctors really don't want to hear from you about all of the minutiae, and the staff cannot be your friends that you vent to. So luckily we have organizations that we can join where we can share our frustrations or our joys with other administrators. But when you are in the midst of something and somebody takes out their anger on you, the ability to pause and sit with it and understand, and this did not come easily to me, but when you look at the doctor comes in then in the morning and he throws his keys on the desk and he's upset and he's running around looking for a clean coat, and it's because he had to break hard and he spilled the coffee all over him, and he's barking at you, but really he's not barking at you. He's expressing his frustration about what went on this morning. Yeah. Same thing goes from an employee's perspective of having a conversation about performance improvement. We're not here to tell you that you're a terrible person. We're here to tell you that the work you're doing is not at the level that we expect. So it's not a personal statement, it is a performance statement. And again, to get that emotional intelligence, it took reading that book five or six times for me to start to see people in a different way. People that are, I saw a great video once of it was people in a hospital that were dealing with different situations, but you didn't know what the situation was until it floated above them. So, you know, the guy who's frustrated when he's getting his coffee, it's because he just learned his wife has a terminal illness. So when you don't know the backstory, it's very hard, it's very easy for you to assume. And that's why if you can just step back and say, I wonder what's going on in their life today that's making them react like this.

SPEAKER_00 10:15

Yeah. This is a huge one, and it's something that you wish all of your employees, in addition to you, you wish all of your employees could understand because you know, how many times has someone get bent out of shape about something or taken feedback poorly? And this is one I could definitely see to be honest, all of these things are things I think you could train your employees on, but not taking things personally, that's a big one. If you're in customer service, it's hard not to take things personally. And boy, if we could educate our employees, you know, on this one, I think that would be a huge, huge one.

SPEAKER_01 10:53

And especially you're dealing with disease processes that could be frightening. And I have been in situations where, oh my god, this patient, she's asking 47 million questions. Well, she's also just been diagnosed with glaucoma, and she's the driver in her household. And if she loses her vision, she can't take her husband to dialysis. There's a whole chapter behind why she's asking 47 million questions. So you're really it's not you're learning not to take things personally, but you're also practicing empathy.

SPEAKER_00 11:31

And that's that is a huge skill to be able to use within the clinic.

Sponsor Seasoned Advice HR Services

SPEAKER_00 11:38

This show is sponsored by Seasoned Advice HR Services, where I help eye care businesses to make more money and save more money by hiring better, retaining better, and reducing your HR risk. If you would like an HR assessment or ongoing HR support, please reach out to me at seasoned-advice.com. Okay, let's go to agreement number three. Why don't

Agreement Three Stop Making Assumptions

SPEAKER_00 12:05

you tell us what that one is?

SPEAKER_01 12:07

So don't make assumptions. So actually, if you look at how all of the agreements flow, they kind of flow into each other. So when you're in that place of don't take anything personally, and you've got a patient asking you 47 questions about the glaucoma drops, the assumption you're making is that oh my god, they're a pain, or oh my god, they're not very smart, or oh my god. But then again, if you're making an assumption about who or what they are and how they're experiencing it, that will show you if you take a minute to hear what the story is. Again, the patient's freaking out because she's the driver in her family, she has to take her husband a dialysis three days a week. Learning this new disease that is the sneak thief of sight, you know, is a very overwhelming thing. Um, but don't make assumptions goes throughout the practice. This goes to talking to patients about premium IOLs. You have a patient come in and they may be dressed in sweats that are dirty and carrying an old bag, and you know, they don't look the type to be able to afford the lens. You don't know what they have in the bank. You don't, you shouldn't not offer a service to a patient because you're assuming what they have or don't have. Don't assume that patients have been dilated before unless you know they have, because anytime you have to tilt your head back and have drops put in your eyes, tech should be explaining the whole process. I'm putting a yellow drop in your eye. I'm going to give you a tissue so it doesn't get on your clothes. That's gonna numb your eye. The next drop is gonna dilate your eye. It's much easier for a patient to say, oh, I've done this 40 times, I know this already, than to have a patient worrying about what you just did to their eyes and why they can't read for four hours. So, this again, you know, if you can communicate this way, if you can start with the patients and then bring it in to your staff and your coworkers, it becomes easy. It becomes a regular day-to-day practice that it's not like, oh, today I have to practice the four agreements. I live the four agreements. I think you live the four agreements. So it's just a repetitive thing that you build that muscle memory and it just flows naturally. Yeah.

SPEAKER_00 14:36

Yeah, I really actually I like the strategy of starting with thinking about patience, right? Because that's that's that's harmless, that's easy to to approach. And then once you understand how to don't take anything personally with patients, don't make assumptions with how you do customer service. Okay, now how about yourself? You know, don't make assumptions with your peers, don't make assumptions, you know, about yourself. Do some of the inner work, I think. So that's kind of an interesting approach, um, starting that way.

SPEAKER_01 15:10

And if you look at, like, for example, I've seen this so many times where there's a you need to have some people stay late. And the assumption is that you're not going to ask Denise because Denise always says no. Well, ask Denise. Maybe something has changed in her life that would allow her to, because other people get frustrated because Denise never says yes. So maybe you're opening an opportunity for a change in behavior all the way around. So I think that's like an easy way to start talking to your staff, asking things that you've always assumed were a certain way.

SPEAKER_00 15:48

Yeah, I can see that coming into play with training as well, and and verifying, hey, do you understand how to do this? Well, show me how to show me how you do that. Like, let's I don't want to make an assumption, show me how it works, or explain to me the procedure for this, because as he says in the book, you know, you're trying to avoid misunderstandings and avoid drama. And a lot of drama comes about because we take things personally and we make assumptions, just like you said. Someone has a frown and we assume that it's about us and then we take it personally, and yeah.

SPEAKER_01 16:24

And I think this is the part of the commercial here where you know, if you don't have SOPs in place, like you have to have the infrastructure in place to be able to implement this. Two and three come into place all the time when it comes to verifying training, like you just said. It's so important to say, show me how you do it, because you could have five techs and all five of them set up the room differently. All five because it depends on who trained them. So when you don't have standardization, then something always gets missed. And that would then lead into the fourth agreement, which is always do your best. Now,

Agreement Four Always Do Your Best

SPEAKER_01 17:09

this is an interesting agreement because this depends on the emotional intelligence and maturity of your staff. When you try and implement this, this is not about perfection, this is not necessarily a contest. This is when I used to joke, I managed to practice in Los Angeles, and so in the morning, you know, 20-something employees coming in grumbling about traffic or their kid threw up or whatever's going on. They had a few minutes to settle in. But then there was an old TV show called Fantasy Island, and Mr. Rourke would come out, and as soon as the guests were arriving to the island, he would say, Smiles, everyone, smiles. And it's like you're putting on your best for the day with the patient. So they knew that when they were clocked in, ready to work, we're going smiles, we're doing our best, we're gonna leave behind whatever we left in the car or at home. Your best can vary from day to day, but as long as you're giving your best effort that day, you might not be feeling well. You can feel a migraine coming on. Your kid was up sick all night last night, but you still came to work and you're gonna give it your level best for that day. And so the slacking is goes away. Everybody is trying to do collect all the money, get copies of the insurance cards, take a good history, make sure you're using the right modifiers, closing out the charts at the end of the day, cleaning up the office before you leave. It's that type of behavior that it again, it just becomes road. You just do it.

SPEAKER_00 18:59

Yeah, and when I think about this one, always doing your best. I like what he says here, where he says, if you if you do your best, you'll avoid self-judgment. And I think, you know, this is about, I think for me, this is about knowing that whatever you're doing, you're doing it your best for that day. Maybe every day will be a little bit different, what your best looks like, but I'm not gonna judge myself. I'm gonna say, you know what, I did my best. And then it almost comes full circle with agreement one, which is being impeccable with your word, because you need to remind yourself, hey, I'm doing my best today. I'm I'm putting my best effort and I am showing up as my best self, you know, get given everything that's been that that's happened today. Now, this isn't necessarily a get out of jail free, and everyone just, oh, you're all doing our best and everything's fine. That's not what this is necessarily about, but it is about taking care of yourself and how you treat yourself. That's how I look at it.

SPEAKER_01 19:58

Absolutely. And again, it goes back to you have to do the legwork of creating the standards. So you can't hold people accountable to standards if you haven't defined them. If you don't have a job description, SOP, you know, verbalized practices that you need to have happen every day. You can't hold people accountable if they don't know.

SPEAKER_00 20:26

Awesome. Well,

Turning Agreements Into Daily Culture

SPEAKER_00 20:27

you you had you had shared with me some thoughts about like how can you apply this in maybe in your life or in your clinic, and I don't know, what can it's a great book. I think everyone should read it, but but how do you think people could actually apply this?

SPEAKER_01 20:44

Yeah, so you know, the the way that it worked best for me was that I did it through journaling. So I held myself accountable by journaling every day. What did I do for each one of these to put them into practice? And I'm not that I was not perfect every day. Some days were not good, but at least by journaling it and having a place to go back and look from, they say culture isn't what you say, it's what you repeat. So if you want to create this culture in the practice, you know, it's gonna start from the top. Um if you can get the docs buy-in as well, you know, I think it even works more magnificently. Um, but I think you will see your patient input and feedback change when they see this being implemented in the practice.

SPEAKER_00 21:46

Yeah, I think so too. I think these are all things that are this is good information for your employees. It's not just for yourself, it's good for your doctors. And I think when you can infuse these ideas throughout the office, every Everyone benefits. One thing that I've done in the past in a few different settings is I've created like a team agreement. And a lot of the things in those team agreements are right here, being impeccable with, you know, we speak kindly with each other, we don't gossip, we don't think things personally. I mean, literally, they're all here in this book. And so you this is a wonderful foundation, I think, to say, hey, this is how we're gonna treat ourselves and each other in a in this clinic.

SPEAKER_01 22:31

Yeah, and if you, you know, you start it out as a conversation. It's a minimal expense to buy a copy of the book for all your staff. I know there's even some workbooks that go along with it. You start to create this as a way that you onboard your staff too. Like this is how we behave. This is a book we're giving you when you start. This is something that you know our whole team buys into. Uh, you want to reinforce the language daily, and you have to model it, and you also have to be willing to have people call you out when you're not living your best second agreement, you know.

SPEAKER_00 23:12

Yeah, and you know, I think one thing I've seen with this stuff, like kind of what you said, is like it can't just be a, hey, I'm gonna put it up on the wall, and maybe we read it once and then we never talk about it. It has to be talked about and re reviewed, and I'm using the words, you're using the words, and we're communicating about it, and and it that's how it becomes part of your culture.

SPEAKER_01 23:38

And you can just start with one start with agreement one.

SPEAKER_00 23:41

Yeah.

SPEAKER_01 23:42

Be impeccable with your word, you know, because once you start modeling at work, I mean it just infiltrates everywhere, and that's not a bad thing. And you know, reward people for change, um, reward the office, you know, like I you've seen a shift, patient surveys have seen a shift, you know. It's not gonna fix your payer contracts, it's not gonna help your staffing shortages, but if you can improve team communication, I mean that is half the battle every day in a medical practice.

SPEAKER_00 24:18

Agreed, agreed.

iMed Management And Closing Thoughts

SPEAKER_00 24:20

Well, Elise, I've really enjoyed this. This has been probably my favorite show just because we weren't talking about marketing or HR thing. Right. Uh but just to bring back to business for a second, I wanted to give you a chance to talk about your your business that you work with, iMed Management. Can you just mention what you guys do and what you're all what you're all about?

SPEAKER_01 24:44

Yeah, so iMed Management Solutions is an ophthalmology only US-based revenue cycle management firm. We work only with three softwares, ModMed, Next Tech Practice Plus, and Advanced MD. Um, we provide training and support for the clinics we work with. Um, and as a little side note, Mike, I am planning to submit the four agreements back to ASOA and AOE with you as my co-instructor. So hopefully you can, if you're watching this and you think this is great, you can bring your staff to these courses at the meeting. Should we be selected?

SPEAKER_00 25:29

Oh boy, that would be fun, wouldn't it? Um well, thanks for joining me. I'll put a link to your in contact info in the show notes. But if you if you've heard the show or you're watching it and you like this, let me know and we'll find another book to talk about or another topic related to personal development. I think that's something that would make a wonderful ongoing topic. But thank you for listening and thanks for being my guest, Elise. Thank you. Awesome.

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SPEAKER_00 26:00

Well, that brings this episode of iCare Leadership Live to a conclusion. If you enjoyed this episode, please subscribe to the show on your podcast app and share it with someone who would value the content. I promise to bring you more guests and content to help make you a better eye care clinical leader. I also invite you to subscribe to my HR newsletter for iCare leaders. You can find information about that at seasoned advice.com. Now go out there and lead with confidence.