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Nicola V. Hawkinson, DNP

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Spine Fellows SymposiumAssembling Your Staff

The practice of medicine is by far one of the most important fields in which people can work. Taking care of peoples health is such an important profession that it should have only employees who take pride in their job and want to come to work each week

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ObjectiveThe Business of SpineCommon MistakesRemember your roots and what you need to growAssembling your staffThe cost of hiring poorlyRunning your practiceThe future of the Spine PracticeWhat SpineSearch can do for you

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The Business of SpineJoining a practice

Starting a practice

Building a road to success

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Your Practice is Your BusinessBest PracticeConsistent ProcessEqual accessGood faith efforts

You need to know how it works!!

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Common MistakesI dont have to worry about.. Staffing, they supply me with a secretary..Accounting, the practice has someone they have used for yearsMalpractice, the group has a policyBilling, the practice takes care of itMarketing/PR, the practice/hospital will promote meStaff education, they have been there for years

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Three biggest office mistakesNot

ListeningSeeingSpeaking

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Dont forget where you came fromOr where you are going..

Strategize your 1st years goal, and 5 yr goals (short & long term)Write them down and have a formalized process to record your progressRevisit your goals/progress on a quarterly basis to keep yourself on trackPutting goals in writing makes them more likely to be realizedDont be afraid to share goal with staffAssign goals to every team member regardless of positiongive everyone something to strive for

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Lessons LearnedNo one will care more about your business than you doListen to those that work with youInvite patient feedback, they are your customersSpending a little extra time getting things correct in the short term will reap large rewards over the long term

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Employ the right number of staffWhy do we have staff?So MDs dont have to perform nonclinical tasks which lowers physician productivity.This is key to remember because there is a tendency to view employees as a cost. When budgets get tight we fire employees, MDs do nonclinical tasks and income drops more creating a negative feedback loop.However employing to many employees can just as big a risk as employing to few

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How to know the right number of staff?

Asses the task of each provider (for multi-physician practices) and staff.Is a physician being interrupted for patient phone calls?Does each physician need a full-time RN, NP, or PA?Are employees in their knowledge areas?Are you appointment schedulers working in shifts so the phones are continually being answered?Are accounts receivables staff seated where they can concentrate or at the busy front desk?Are accounts receivables going past their average collection times or for new practices past the industry averages?

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Compensation: This is only part of the package!Study after study has salary low on the list of motivating factors. Higher on the list are the ability to balance personal and professional life, a sense of purpose and meaning of work, trust among employees and a good relationship with the supervisor or manager.Know your staffWhat makes them tick???Ask them What is important to you?

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Now key attributes for different age groups and any other charactersitics that might differentiate the staff of your office

Some examples: Baby boomers often strive for public and peer recognition, promotion and control in addition to higher salaries. Workers born after 1969 tend to place the following above salary; positive mentoring experience, continual challenges, continuing education.Given choice of extra time off or a monetary bonus younger workers often prefer time off

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Keys to success with exisitng office staff and hiring new onesDefine job rolesForm Mentor/protg relationshipsDevelop a strategic plan for employees

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Define job roles:Most jobs in a medical office are self explanatory right? A biller bills, a receptionist answers the phone, a nurse sees patients and assists the MD. On the surface perhaps, but consider this example: One of your top secretaries schedules 10 new patients to be seen on Monday. No one tell the rest of the staff and when Monday comes all hell is breaking loose in the office by 0900. The secretary assumes that the office manager will tell the MD, the RN, and other administrative staff to have all documentation and to leave a little extra time between other patients to handle the large amount of new patients for that day. The Office manager assumes the secretary will tell everyone, the MD assumes some one will tell him, and the assuming goes on and on. Without clearly defined jobs you have a problem on your hands!

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Define Job RolesThankfully, there is a simple way to solve this problem. Each person on your team needs a job description.Job descriptions help to Clarify roles and responsibilities everyone knows exactly what they are supposed to do. Increase morale because its clear what it means to do a good job and what it means to go above and beyond.

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Define Job RolesA job description will rarely be a laundry list of every single task associated with a job.

As a business owner you are responsible for defining the roles of those who work for you but you dont have to go it alone. Invite those currently executing the job to provide feedback on what they think their job is and what it should be. This can be a very revealing exercise!

SpineSearch has a vast amount of experience in creating useful and efficient job descriptions both from an institutional setting as well as an office setting. If you would like us to assist in helping customize job descriptions to help maximize efficiency in your office do not hesitate to ask!

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Define Job RolesIn most cases, job descriptions do not need to be overly complex especially if you are a small company. A good job description will Explain the major functions, duties and responsibilities of the job. Highlight the specific skills that are most relevant to the job. Explain what its like to work in your environment.

What position have your employees been assigned? Do they know?

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Define Job RolesFacilitate the recruitment process because the job you are looking to fill is clearly defined so it is easy to explain to prospective candidates.

Define career paths within your company. Those more junior can see what it takes to execute a job more senior to their own. Impact the bottom line. When everyone performs the necessary tasks you can be certain patients are being properly serviced so theyll come back to you again and again!!!!

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Form Mentor/protg relationships

Use your strong staff members to assimilate, train and mentor new staff until they are up to speed with proper procedures. Although many medical practice administrators have graduated from rigorous academic programs, few in any, have left those programs with the wealth of skills that are needed for successful health care management. This matter is further compocated by the fact that in most cases, the health care industry does no provide formalized corporate training for its managers or any other staff. Utilizing a well trained office manager or other higher level staff member to bring new staff members along the e proper path is critical to getting what you want out of a new higher

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Develop a strategic plan for employeesWhere there is a problem, the decision-makers in the medical group must take ownership and commit to improve the issue. Have a strategic plan of action to presenent to the MD, partners, or board of directors depending on the structure of your organization. .

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Develop a strategic plan for employeesAvoid the temptation to fix the squeaky wheel employees with small increases or changes without have an overall plan.

Strategic Planning require evaluation of many areas to review thoroughly before developing a plan of action. Practice evaluation should include areas such as number of staff, work turnaround time, and volume of work in objective measures as well as employee surveys to assess their ideas for improvements. This type of approach prevents what is frequently called the Band-Aid fix, which brings only temporary solutions and may actually make the problem more costly in the future.

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Develop a strategic plan for employeesMany times employers will rush into an overall salary increase as a plan of action to decrease turnover. As I have discussed previously salary increase is frequently not the best action plan to prevent t employee turnover

Ask questions, speak with multiple staff members, develop a well thought out plan before you act!!In addition to a strategic plan for situations that arise in your practice I would highly recommend developing a set of standard operating procedures for your office.

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Standard Operating ProceduresSOP'sWe can spend thousands or even millions of dollars building an office, buying medical equipment, purchasing sophisticated software, hiring powerful marketing firms that will perform every day exactly as we want. We can adjust and modify all equipment, customize the software, consult with all the PR firms in the world and we can have an information system that gathers important data about every patient & insurance provider that is seen. But if we cant employ a workforce that operates the office consistently and efficiently then the whole operation will fail.Full adoption of the standard operating procedure (SOP) process can go a long way toward ensuring that the necessary workforce is in place. The full SOP process includes planning, developing, implementing, and monitoring. This simple guide will help demonstrate the need for SOPs and how they can be a big part of managing human resources

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Standard Operating ProcduresStandard operating procedures are a means to remove variation in work performance caused by people completing the same work processes in different ways.A process is a set of actions that a person or group of people must perform in order to complete a job. A standard operating procedure describes the steps that people should use to complete the process. Thus, in a medical office, phone triage is a process, seeing a new patient is a process, collecting insurance information is a process, billing is yet another process. I am sure you get the picture and the list goes on

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Standard Operating ProceduresVariation in processes can lead to reduced patient satisfaction, poor payor mix and less referrals among other negative out comes. But since some variation is normal, how can it have such an impact on performance? The answer is that there are two types of variation. The famous management educator W. Edwards Deming defined common cause variation as the result of the myriad imperceptible changes that occur in the everyday operation of a process. Fluctuation in time it takes to see a new patient from start to finish by only a few minutes is likely due to common cause variation and is ok. A 45 minute delay is mostlikely due to lack of procedures being followed and needs to be analyzed and corrected

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Standard Operating ProceduresThe SOP Process and Human Resource ManagementMost people think of a standard operating procedure as a piece of paper that contains step-by-step directions about how to complete a job. That image is correctin part. However, in orderto get the full benefit of managing with SOPs, one needs to think in terms of an SOP process.The SOP process includes planning for results, development, implementation, monitoring, and performance feedback; all of which are proven elements of effective human resourceManagement.

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Standard Operating ProcuduresA good SOP process is about engaging the creative talents of managers, workers, and advisors in a cooperative way. When this is done well, the result is an outstanding procedure that everyone feels committed to. Attempting to create SOPs at the management or advisor level and then simply imposing them on workers is an exercise in futility. Imposing SOPs on others without their input leads to resentment, rejection of the SOP, and countless small acts of sabotage that defeat the purpose altogether

The right way to design SOPs is in a participative manner. Participative management means encouraging everyone that will be affected by the SOP (the stakeholders) to contribute to its development. Leading this process takes practice, but it is worth the effort because teams ofpeople will always outperform individuals.

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Standard Operating ProceduresBe aware of 5 obstacles to overcome when trying to work with your team to produce an SOP. Rememberemployees arent used to having any input in what goes on at their job!1. Resistance to change. Working together to create great procedures is a radical change for some medical organizations. Leaders need to make sure that everyone knows what is happening and why.2. Mistrust by workers of managements motives. Workers are used to just working, not contributing to improvement. It is critical for the leader to create an atmosphere that fosters development3. Lack of clear expectations. Workers may not be sure how much to contribute or what is appropriate. Reassure them that they wont get into trouble for bringing up their ideas.4. Lack of participative skills. Managers, employees, and advisors all struggle with this at times. Make the opportunity for input as non-threatening as possible. Once again, sometimes an outside facilitator (SpineSearch) may be necessary.5. Lack of commitment from top management. Without commitment from the top to support participation, there is no chance for an SOP process to succeed

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Standard Operating Procedures

Plan For ResultsJust like other management activities, advance planning greatly increases the chance of success with standard operating procedures. The person or small team that will lead the SOP development process needs to make plans and decisions before the development process can begin with the other stakeholders. Decisions that should be made in the planning stage include the following:

What business goals will the SOP help to achieve? Clearly define the process and products that will improve when the SOP is in place. Illustrate for everyone why the process is important and how it contributes to individual and business success. For example, the goal of a spine practice SOP is to efficiently and quickly see patients in a professional manner and eliminate mistakes and unnecessary delays. Standard operating procedures work best when they are designed to achieve specific results. How will we monitor performance so that we know workers are following the SOP and so that we have information to feed back to the workers? SOPs are about reducing variation introduced by people. We must be sure that everyone understands the procedure and follows it.

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Standard Operating Procedures

Plan For ResultsJust like other management activities, advance planning greatly increases the chance of success with standard operating procedures. The person or small team that will lead the SOP development process needs to make plans and decisions before the development process can begin with the other stakeholders. Decisions that should be made in the planning stage include the following:

What business goals will the SOP help to achieve? Clearly define the process and products that will improve when the SOP is in place. Illustrate for everyone why the process is important and how it contributes to individual and business success. For example, the goal of a spine practice SOP is to efficiently and quickly see patients in a professional manner and eliminate mistakes and unnecessary delays. Standard operating procedures work best when they are designed to achieve specific results. How will we monitor performance so that we know workers are following the SOP and so that we have information to feed back to the workers? SOPs are about reducing variation introduced by people. We must be sure that everyone understands the procedure and follows it.

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Standard Operating ProceduresHow will we monitor results to know if the SOP itself is properly designed to be effective? The old saying, If you cant measure it, you cant manage it, definitely applies here. Think about what you will measure. These indicators would show how efficiently patients are seen and how effective the procedures are at preventing delays and mistakes. What type of procedure format should I use? There are a lot of ways to present an SOP. We cant go into detail about the many different formats in this presentation but SpineSearch is available to discuss formats, creating, monitoring and any other part of the SOP process you desire How can I get everyone (management, workers, and advisors) to buy into this SOP? If you cant get everyone on board, it wont work.

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Standard Operating ProceduresDevelopmentOnce the leadership has answered the five questions in the planning stage, it is time to move onto development. It is in the development stage that the procedure is opened up for input and review from the stakeholders: workers, other managers, and other advisors.ImplementationAfter a satisfactory standard operating procedure is developed and tested, it is time for implementation. The SOP leader needs to make sure that everyone receives a copy of the SOP to study and review. In addition, the SOP should be posted, if possible, in the workplace where it will be completedMonitoring and FeedbackMonitoring stems from the performance goals that leadership established in the planning stage.An effective monitoring system really must measure two different things:1. Are all the workers consistently following the SOP, and2. Is the SOP designed correctly to achieve the desired results?

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Standard Operating ProceduresConclusionsNo quick fix is possible to remove variation introduced when different people complete a process. A thorough standard operating procedure program can remove much of the variation by bringing workers, advisors, and management together to design the best possible procedure. Perhaps the best benefit of the participative SOP process is that many challenges can be solved at once. A participative style makes managers better, it leads to happier and more motivated workers, and it creates procedures that are far more effective than when management designs them alone.

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Turnover costs: Prevent your practice from having a turnstilefor employeesBecause it costs more to replace staff members than to retain them, you should continually monitor your practices turnover rates by job classification and set realistic goals for monitoring performance yearly.

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Turnover costsThe total cost of replacing an employee runs 50% to 150%. The higher percentages usually apply to managerial staff. Thus, it can cost your practice $75,000 to replace a $50,000-a-year employee. Those percentages include related costs, such as recruitment, hiring, training, use of temps, and lost productivity for six months.

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Turnover costsMGMAs 2006 Survey on indicated turnover rates:25% for receptionists and medical records staff16.59% for nursing and clinical support staff10% for billing/collections and data entry staff1.56% for nonphysician provider staff

If your turnover rates exceed these median rates, you should determine the reasons, measure general employee satisfaction and outline steps for reducing staff turnover.

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Turnover costsDo you survey departing employees why they leave the practice?Exit-interview surveys reveal issues and trends that lead to turnover and help you develop plans to reduce it.Sample Questions:What influenced your decision to leave?How could the group have made your job more rewarding?How has management responded to your concerns?What did you like/dislike about the practice, it works processes and your interpersonal relationships?Were the salary and benefits adequate for your responsibilities?

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Turnover costsEmp0lyee-satisfaction surveys distributed to all staff members also reveal areas that need to be addressed. If youre determined to improve employee retention, you should also look at what you offer. Employees are more apt to remain in a pratcice that:Offers attractive salary/benefitsAllows flexible schedulingSupports continuing education and advancementHas effective relationships among supervisors and physiciansListens to employees suggestions and ideasOffers a sense of community in the workplace

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The War for TalentIn todays business, practices not only compete for patients.they compete for Make your practice attractive, potential candidates do have choices in the health care field make them want to be with your organizationPast performance is a good indicator of future successLittle can be learned on an interviewHave candidates spend a day in the lifeBoth you and employee will have better idea One bad day is better than one bad year

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Why keep staff happy?The staff in your practice have the intellectual capital to do their job descriptions. They can take that information to a practice across town any time they want.

Finding the talents that people in your practice have, inviting them to use them and rewarding success whey they do is paramount in successful management.

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Reward Top Employees

You want to make sure to set realistic goals so the employees can actually accomplish some ofthem without having to operate on a fully optimal basis, if all goals are unobtainablethen you will decrease moral not improve it.Some suggested goals:Average time to see a patientAverage time to collect from insuranceNumber of patients seen per day, per moth, per quarterTime to follow up on a patient messageTime to follow up on a patient complaint

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Reward Top EmployeesWhen individual and are office goals are met employees need to be rewarded. Recognition does not always have to be financialthe focus should be on the achievement not the reward.General ideas but be creative to the specific employee and or goalCash rewardHalf day or day off (Friday?)Dinner with spouse or significant other on the officeOffice partyExtended LunchAlso reward Length of Service (LOS). If you want to promote loyalty for staying with your practice. Promote a culture that not just rewards achievement but also length of service with your office 1yr, 5yrI think you get the idea

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Current Unemployment RatesWhat does this mean for you??Influx of employees into healthcareMore resumes, not necessarily more qualifiedNeed for proper screeningOpportunity for smart business practice to obtain highly qualified professionals

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Office EfficiencyLAS VEGAS -- One of the best ways to improve your office efficiency is to train and retain good staff, Dr. David M. Pariser advised at the Fall Clinical Dermatology Conference. "You spend more time with your staff than you spend with your family," noted Dr. Pariser, professor of dermatology at Eastern Virginia Medical School in Norfolk. "You want your employees to know what your expectations are, and you would love for them to be able to exceed those expectations."

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Monitoring ResultsOnce a major program has been put into place, regular monitoring must be done in many areas. Besides employee surveys and turnover reports, evalutations of the employee salaries in the market are also important. Annual review of the market for salaries of key positions is essential to prevent turnover increase because of low salaries. Also try to speak with other peers in your industry to stay on top of industry trends

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Hiring Dont believe the squawk: How not to hire a turkey!When hiring employees, its tough to find the eagles in a flock of turkeys because the latter have learned to disguise themselves as the former. With the right selection tools and a few tips, though, you can increase your odds of hiring someone who soars rather than squawks.

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HiringJust as you make a list of features you desire when shopping for a new car, develop a shipping list for new hires. You should hire for attitude and train for skills. Skills dont mitigate a bad attitude or disruptive personality

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Another useful idea is a performance profile. This is a prioritized list of the top six or eight things a person in the job must do to succeed or excel in the position. It describes the positions primary performance objectives, key sub-tasks and challenges. You should look for people who have accomplished similar tasks at other jobs. By developing performance profiles, you also ensure that if you have more than one individual involved in hiring that the process looks for the same attributes in applicants.

A thorough hiring system and valuable tools allow you to hire the right person the first time!Hiring

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HiringDont under estimate employment applicationsprospective employees fill them out on site and record how long it takes them. Look for other indicators, too. For example, did they leave blanks when they where told not to?

Applications can be more valuable than resumes because they tell you what you want to know; a resume tells you what the applicant wants you to know

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HiringDont use employment applications or resumes- as the basis for interview questions. Instead, develop a standard guide for the position. Ask open-ended or situational questions and take notes.

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Hiring5 Important questions to ask:Tell me about the first job you ever had. Because the first job they ever had could have been years ago and unrelated to the one for which theyre applying the applicants dont expect this question. The answer may review their values and ethics.Tell me about the achievements in your life that you are most proud of and the obstacles or problems you have overcome. The answer will give you indication of what motivates the applicants

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Hiring5 Important questions to ask:Tell me about your last performance appraisal. An applicant revewls his/her level of self-esteem and feelings about anothers appraisal.Ona scale of 1 to 10, how would you rank yourself as a (insert job position)? Then ask what it will take to get them to the next numberWhat one question would you like to ask me? After asnwering, ask, Why, of all the question you could have asked, did you choose that one? Role ereversal is always informative, plus the question reveals an applicants #1 priority.

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HiringPositioning applicants to tell the truth is also a critical part of the interview. Let them know what the interview process will consist of and what you expect from them. Tell them that you will be truthful with them and ask them to be honest with you

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Dorothy Sweeney, a popular employment theorist, feels many employees leave because of burnout, and she expresses the symptoms of burnout as frequent absenteeism, low morale, and high turnover.Sweeney also supports the argument that burned-out employees are costing employers major dollars to the bottom line each year. Expenses related to burnout, such as high absenteeism and low productivity, are fairly easy for employers to spot.Hiring

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Staff

Other non-employed staff members that you will need to orientate with how you want to work. Keep in mind some of these non-employed staff can and will be just as important as your employees to the success of your practice.1) Medical Technology Reps2) Imaging Locations3) Physical TherapistsOutside billingMarketing Companies/PR personal???

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In ConclusionThe staffing of your office is a critical link in the longevity of your success as a physician and a key cog in your ability to expand, service, and bring in new business. Ultimately if your staffing function breaks down so will your ability to see and treat patients. Your staff is the first impression of your office and we all know first impressions last for ever (put in Maxs picture with the underwear on his head)

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Advice from the trenches

10 years running spine practiceImportance of phone triagePatient satisfactionReview of accountsAnalysis of referralsUnderstand the responsibilities and importance of each positionMany connections with experienced MDs who have learned from the school of hard knocksLet SpineSearch help you learn from their mistakes

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