How Many Staff Members Do You Need? -- Family by San Diego Physician

How Many Staff Members Do You Need? Crystal S. Reeves, CPC

While there’s no one staffing formula that fits every practice, industry benchmarks can point you in the right direction.

any physician practices struggle long and hard with finding just the right number of staff members to work in just the right jobs at just the right time. Few practices ever master the struggle and reach staffing “utopia.” Those that do attain favorable staffing levels and stability tend to experience it only briefly. The mistake many practices make is adopting an oversimplified and reactionary approach: If the work falls behind or everyone is pleading for help, they add staff. And if overhead expenses grow too high, they cut personnel costs.

Over-staffing brings an increase in costs, but not always a

ILLUSTRATION BY MICHAEL SPRONG

corresponding This backward-looking approach seldom works, creating a pendulum effect that results in having either too many or too few staff members on board. Over-staffing brings an increase in costs, but not always a corresponding increase in efficiency or quality. Under-staffing can lead to decreased patient Crystal Reeves is a principal of The Coker Group, a national health care consulting firm in Atlanta. She is also an author and national speaker on medical practice management issues. Conflicts of interest: none reported. September 2002

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SPEEDBAR ®

➤➤ Many practices take an oversimplified and reactionary approach to staffing: If work is behind, they add staff. If overhead expenses are too high, they cut staff.

➤➤ The most effective way to determine your staffing needs is to consult industry benchmarks, allowing adjustments for unique circumstances within your practice.

➤➤ To ensure you are comparing apples to apples, understand how the benchmarks you are consulting were derived and follow the same methodology in calculating your own numbers.

➤➤ The support-staff-perFTE-physician ratio indicates the number of full-time staff members it takes to support one full-time physician in a given practice.

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satisfaction, reduced collections and poorer financial performance. So what is the secret to successful staffing? Although the answer depends greatly on hiring people whose work ethic, experience and expertise make them well suited for the job, physicians can attain a general idea of their staffing requirements by comparing their practices to industry benchmarks and making adjustments to the numbers, as needed.

KEY POINTS • Practices can begin to assess their staffing levels by consulting industry benchmarks, which are widely available. • When comparing their staffing levels to benchmark data, practices may need to adjust their numbers based on unique circumstances. • High physician productivity may justify higher staffing levels than the benchmarks suggest.

How to do it The first step in benchmarking is to find The support-staff-per-FTE-physician ratio reliable sources of data for physician pracindicates the number of full-time staff tices, such as the Medical Group Managemembers it takes to adequately support ment Association (MGMA), Practice one full-time physician. (Midlevel providers Support Resources (PSR), the American are not included in this calculation but will Medical Association (AMA) and the Ameribe accounted for later under “Adjusting can Medical Group Association (AMGA), the numbers.”) The Medical Group Manas well as local medical societies (see the list agement Association (MGMA), one of on page 48 for contact information). When the leaders in practice benchmarking, uses comparing your practice with industry the following methodology to determine performance standards, try to find data FTE physicians: for practices similar to yours and consult at 1. Determine how many physicians in least two sources for a broader perspective. your practice work “full time” (defined as the The next step is to determine what to minimum number of hours considered to be measure. When it comes to staffing, most a normal workweek in your practice). practices want to know the answers to two 2. For each physician who works less than questions: Do we have enough individuals full time, divide his or her average number to do the work? And are our staffing costs of hours worked in a week by the full-time in line with those of other similar practices? standard to determine FTE status. For To answer these questions, look for example, if Dr. A works 30 hours a week in benchmarks that address the following: a practice that considers 40 hours to be full 1. The number of support staff per fulltime, his FTE status is .75 (30/40 = .75). time-equivalent (FTE) physician, 3. Based on steps 1 and 2, above, calcu2. The percentage of gross revenue spent late your total number of FTE physicians. on support staff salaries. For example, if you have two full-time The grid on page 47 shows two sets of physicians and two physicians who each staffing benchmarks – one from PSR and work 30 hours per week in a practice where one from MGMA. 40 hours is a full workThe third column in week, your number of Many practices cannot accept FTE physicians would the grid provides a place for practices to be 3.5 (1+1+.75+.75=3.5). their numbers at face value. enter their own data Follow the same for comparison. For process for determining practices to be able to compare “apples to your FTE support staff. Then, divide the apples,” it is important that they understand number of FTE support staff by the number how these benchmarks were derived and fol- of FTE physicians. This quotient is your low the same methodology in calculating staffing ratio. For example, 15 FTE support their own numbers. Different surveys may staff divided by 3.5 FTE physicians = 4.3 use different methodologies (you can usually FTE support staff per FTE physician. find them described within the survey docuStaffing expenses as a percent of revment), but they will generally resemble enue. To determine staffing expenses as a the following: percent of revenue, divide the amount paid Support staff per FTE physician. in staff salaries by gross revenue for the same

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September 2002

STAFFING NEEDS

period. For MGMA benchmarks, this figure includes support staff salaries and benefits. Others, such as Practice Support Resources, Inc. (PSR), include salaries only. A practice should be able to obtain its staffing expenses from the year-to-date information available on its profit and loss statement.

• Ambulatory visits per week: 95 to 125, • Inpatient visits per week: 6 to 12. (According to PSR, these ranges cover about half of the practices surveyed, with about 25 percent above and 25 percent below the ranges.) Using these figures, a practice may want to adjust the number of FTE physicians it uses in estimating approAdjusting the numbers priate staffing. Physicians whose productiviMany practices cannot accept their numbers ty figures fall near or beyond the extremes of at face value. Extenuating circumstances these ranges may cause a practice’s actual within practices often number of FTE physihave an effect on staff cians to be misleading. size requirements or The well-organized physician For example, consider account for staffing a practice with three will probably require fewer salaries that are higher or FTE physicians has lower than benchmarks. total annual gross support staff than one who For this reason, practices charges of is less organized. should consider the fol$1,800,000. If you lowing points before divide total charges by deriving any conclusions the range maximum, regarding their staffing numbers. $550,000, the adjusted FTE physician numMidlevel providers. Practices may ber comes to 3.27. The higher physician need to adjust their target staffing levels productivity could warrant higher staffing based on whether they employ nurse practilevels. tioners or physician assistants. For example, Satellite locations. Satellite locations are the MGMA 2001 Cost Survey 1 provides a great way to increase a practice’s patient benchmarks of 0.38 MLPs and 4.67 support base, but sometimes they call for heavier staff per FTE physician in family practice. staffing. If the satellite location functions as a If your practice has no midlevel providers, full-time independent practice with its own your staffing needs may be lower. If your support staff, then its staffing levels should be practice has a high number of MLPs per comparable to those of traditional practices. physician, you will likely need more staff However, if a practice’s satellite location is than the benchmarks suggest in order to support the additional A QUICK COMPARISON providers. Physician productivity. The grid shown here provides two sets of staffing benchmarks for Practices may also need more or family practice (one from Practice Support Resources’ 2001 Practice less staff than the benchmarks Management STATS Quick Reference and one from Medical Group suggest depending on the numManagement Association’s 2001 Cost Survey). Practices can list ber of patients each physician their own staffing numbers in the third column and compare and sees in a day and the number of adjust their numbers as needed. PSR provides a range for surveyed procedures and ancillary services practices, while MGMA provides the median. Other sources of the office provides. Therefore, benchmarking data are listed on page 48. when comparing FTE physicians, it is also advisable to compare gross charges per physician PSR MGMA Your practice or the number of visits per week Support staff per 3.0-5.0 4.67 or per year. FTE physician For example, PSR’s 2001 Support staff cost 25-27% 31.57% Practice Management STATS as a percentage 2 Quick Reference provides the of gross revenue* following physician productivity benchmarks for family physicians: *PSR includes only support staff salaries in this calculation; MGMA includes support staff salaries and benefits. • Total annual gross charges: $417,000 to $550,000, September 2002

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SPEEDBAR ®

➤➤ Special circumstances within a practice may account for staffing levels that are higher or lower than the benchmarks.

➤➤ Practices that employ midlevel providers may require more staff to support them.

➤➤ Physicians who are extremely productive, or those who see fewer than, say, 90 patients per week, may cause a practice’s actual number of FTE physicians to be misleading.

➤➤ Physicians’ practice styles and degree of organization can also affect the number of staff they need to support them.

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SPEEDBAR ®

➤➤ A practice with highly experienced staff members may operate smoothly with staffing levels below the benchmarks.

➤➤ If a practice outsources functions such as billing and bookkeeping, it could justify staffing levels that are less than the benchmarks.

➤➤ High staffing costs (figured as a percentage of revenue) could indicate a revenue problem, not a staffing problem.

➤➤ Staffing costs may need to increase in the short-term to strengthen revenue in the long-term.

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used only part of the time, with physicians impact staff members’ efficiency. If your and office staff floating between the two staffing levels are higher than the benchfacilities, the practice’s total staffing needs for marks, consider whether your practice style, the two locations may be slightly greater. facilities and equipment justify the addiPractice styles. Physicians should also tional staff, or whether your practice needs consider how their improvement in one or practice styles affect more of these areas. their staffing needs. Staff expertise and Reducing staff to save The well-organized experience. Practices physician who sees money can be like stopping also should bear in mind patients on schedule that the experience and your watch to save time. and completes paperexpertise of their support work in a timely manstaff will often have an ner will probably effect on the number of require fewer support staff than one who is support staff needed. If the practice’s less organized. Likewise, staff members who employee-turnover rate is high, that usually must deal with patients disgruntled from means the practice is functioning in “trainextensive waiting, or who must search ing” mode a large portion of the time. New through piles of charts to find the record employees generally require more time to they need, will not be able to accomplish as perform routine tasks and responsibilities much work in a given time period. An than do veteran workers. Those staff memoffice’s layout, its practice management sysbers who have been with the practice for two tem and patient demographics can also or more years are likely to perform their jobs more efficiently, to look ahead at what needs to be done, to make decisions on their own BENCHMARKING RESOURCES and to relieve the doctor of some low-level tasks. If your staffing ratio is high compared Physicians can access reliable benchmarking to the identified benchmarks, figure the perinformation from a number of resources, centage of staff members who have been including the following: with your organization for less than one year. If this number is over 30 percent, it American Medical Association may explain why your staffing levels are Physician Characteristics and Distribution in the US high. To cut down on the number of staff (AMA members: $150; Nonmembers: $170) and members you’ll need in the future, begin Medical Groups in the US (AMA members: $74.95; exploring ways to attract and retain more Nonmembers: $99.95). Call 800-621-8335 or visit experienced staff members. www.ama-assn.org/ama/pub/category/2672.html. Work performed by others outside American Medical Group Association the practice. A practice’s staffing needs Medical Group Compensation & Productivity Surare also affected by the duties it delegates vey (AMGA members: $175; Nonmembers: $250) to others outside the practice. For example, and Medical Group Financial Operations Survey physicians may receive services from a (AMGA members: $175; Nonmembers: $250). Call hospital network or a management services 703-838-0033 or visit commerce.amga.org/store/ organization (MSO) – services such as mancategory.cfm?category_id=2. aged care contract negotiation and credentialing, transcription, billing, human resource Medical Group Management Association management and general bookkeeping Cost Survey (MGMA members: $240; Nonmembers: functions. Adjusting for those functions $450) and Performance and Practices of Successful will alter the number of staff members your Medical Groups (MGMA members: $265; Nonmempractice requires. bers: $475). E-mail surveys@mgma.com, call 877To gauge how large an adjustment to make 275-6462, ext. 895, or visit www.mgma.com/surveys/. for work performed outside the practice, you Practice Support Resources Inc. can consult MGMA’s Cost Survey, which Practice Management STATS Quick Reference, Indibreaks down the median number of staff vidual Specialty ($45) and 14 Specialties ($199). Call members per FTE physician by job responsi800-967-7790 or visit www.practicesupport.com. bility as shown in the table on page 49. If your practice does not perform clinical

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STAFFING NEEDS

Moving forward Once the practice has completed the benchMGMA’s 2001 Cost Survey, breaks down the median number of staff marking process, the members per FTE physician for family practices as shown below. (Warning: physicians and practice Do not expect the sum of these numbers to equal the overall median staffleaders need to ask themper-FTE-physician ratio; that is determined separately.) selves the following quesGeneral administrative 0.24 tions before making any Business office 0.80 staffing changes: Managed care administrative 0.16 • Am I happy with the Housekeeping, maintenance, security 0.14 way the practice is curMedical receptionists 1.0 rently functioning? Medical secretaries, transcribers 0.34 • Am I willing to Medical records 0.43 improve my own efficienOther administrative support 0.13 cy so I require less staff RNs 0.44 time? LPNs 0.40 • Am I willing to pay MAs, nurse aides 0.76 more for staff in order to Clinical laboratory 0.34 attract and retain more Radiology and imaging 0.21 experienced workers? Contracted support staff 0.23 • Are my staff and patients satisfied with the way the practice functions? lab and radiology services and sends tranIf a practice’s staffing levels are slightly scription to an outside source, for example, higher than the benchmarks yet its perforthe total number of full-time staff you mance is strong in other key areas, its physirequire is probably going to be less than cians should be cautious about reducing MGMA’s benchmark of 4.67 per physician. staff. Studies performed by MGMA, as well Staff salaries. The final adjustment as other private organizations, illustrate that involves comparing staff salaries to gross rev- better-performing practices (those with high enue. When using this comparison, it is patient satisfaction levels and high revenue) important to be aware that revenue (the tend to have slightly more support staff per money brought into physician. This findthe practice) depends ing highlights the Better-performing practices tend problem of taking largely on the staff ’s ability to get the benchmarks at face to have slightly more support work done. Undervalue, a factor that staffing in the billing needs to be parastaff per physician. office or inexperimount in the minds enced staff at the of physicians and front desk will usually result in lower revmanagers as they pursue the most favorable enue for the practice. Thus, reducing staff to staffing levels for their practices. Only by save money can be like stopping your watch combining industry data with your own to save time – a futile exercise. In fact, unique knowledge about your practice will staffing costs may need to increase in the you be able to move forward with an short-term to strengthen revenue in the enlightened staffing plan. long-term. If your staffing costs as a percentage of Send comments to fpmedit@aafp.org. revenue are much greater than comparison figures, first examine whether you have a revenue problem, not a staffing problem. For 1. Cost Survey: 2001 Report Based on 2000 Data. Englewood, Colo: Medical Group Management example, your fee schedule may be too low, Association; 2001. you may have poor managed care contracts 2. Practice Management STATS Quick Reference or you may need to improve your collec(Family Practice). Independence, Mo: Practice tions. Revenue problems can paint a darker Support Resources; 2001. staffing picture than actually exists. MGMA STAFFING BENCHMARKS BY JOB CATEGORY

September 2002

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SPEEDBAR ®

➤➤ Before making staffing changes based on the benchmarking process, physicians should examine how well their practice is functioning overall.

➤➤ If a practice’s staffing levels are slightly higher than the benchmarks yet its performance is strong in other key areas, its physicians should be cautious about reducing staff.

➤➤ Better-performing practices tend to have higher staffing levels.

➤➤ Combining industry data with your own unique knowledge about your practice will produce an enlightened staffing plan.

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uestions You Should sk When Hiring

Choosing the best candidate for your staff depends a lot on selecting the right interview questions. Peter Cardinal, MD, MHA

eveloping questions for job interviews is a critical part of your practice’s hiring process. Crafting questions with the skills and personality of your ideal candidate in mind will help you make a wise hiring decision. To find the person best suited for your staff, you should formulate questions that will elicit both informative and useful responses from your interviewee. Here’s how:

can always teach specific skills later. However, it is exceedingly difficult to change someone’s approach to work or rapport with others once he or she is on the job. You should design interview questions that will enable you to assess these attributes in your applicants and to do it in a fairly brief verbal exchange, which is rather difficult.

Dr. Cardinal is the vice president of medical affairs at Gettysburg Hospital, a 100-bed community hospital in Gettysburg, Pa. Conflicts of interest: none reported.

First things first It’s been said that “if you don’t know where you’re going, any road will get you there, but you won’t know when you’ve arrived.” Before you begin interviewing candidates, look carefully at your practice characteristics and the personalities and skills of your staff members to help determine what attributes you want your new hire to possess. Some of

A key concept to remember is to hire for values, attitude and aptitude first, and skills second.

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ILLUSTRATION BY MICHAEL SPRONG

these might include good work habits, friendly and efficient service to patients, stability, enthusiasm, good judgment, general intelligence and job skills. A key concept to remember is to hire for values, attitude and aptitude first, and skills second. If you interview a person with a great attitude and reasonable aptitude, you ■

June 2003

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Getting down to business KEY POINTS Two general approaches to interviewing are to ask open-ended questions and to ask the • Compose a wide variety of questions that will help person to describe how he or she actually you evaluate a candidate’s skills and personality. dealt with a situation or performed a skill • Ask open-ended or scenario-driven questions to in the past. I also like to use a number of encourage relevant, substantial and useful responses. scenario-driven questions to try to determine how the applicant might respond in a • To get a more complete view of your candidates’ realistic medical office environment. These strengths and weaknesses, contact their previous approaches will provide much more useful employers for references. information than questions requiring only a yes or no response. For example, rather than asking a potential nursing assistant, “Do you you think this type of job entails and what know how to take blood pressure readings?” you might like and dislike about the work.” have the candidate describe how he or she 2. Customer service attitude: “Consider would take a patient’s blood pressure. Or the following scenario: An obviously even better, say, “Here is my arm and a annoyed patient calls to complain that he blood pressure cuff. Please take my pressure just waited more than half an hour in the and describe the procedure as you go.” pharmacy only to find out that his refill Since the interview process will be somehad not been called in. How would you what different for every practice, the quesrespond?” tions I suggest below are 3. Conflict only meant to help you management: Your practice should set generate your own ideas. “Describe a conflict Questions obviously will you’ve had with other its own criteria for assessing staff members and vary depending on the position you’re trying to how you resolved it.” candidates’ responses. fill. There are no right or 4. Respect for wrong answers; your patient privacy: “A practice should set its own criteria for assess- patient calls in and notes that his wife is ing candidates’ responses. This is also a great there at the office seeing the doctor, and he time to review and update the position job asks how she is doing. How would you description, or create one if one doesn’t exist respond?” [see “Five Steps to a Performance Evaluation 5. Motivation: “Tell me about a time System,” FPM, March 2003, page 43]. when you saw room for improvement in Here are some sample questions to guide some area of your work environment or a your evaluations of potential employees: process that could be more efficient. What 1. General knowledge: “Describe what did you do to change the status quo?”

SPEEDBAR ®

➤➤ Choosing questions for interviews requires a thorough understanding of your practice’s characteristics and the skills and personalities of your staff.

➤➤ Questions addressing professional ability should be mixed with questions addressing attitude and values, the answers to which can be equally, if not more important to consider.

➤➤ It can be difficult to assess a candidate in a brief verbal exchange, so ask open-ended or scenario-driven questions to obtain the most detailed and useful responses.

BEFORE AND AFTER THE INTERVIEW

If you are in charge of setting up interviews, make sure to coordinate who will conduct the interviews and how they will be organized. The senior administrator or nurse should be involved in interviews for positions in their areas, and physicians should be included if they’re likely to have significant contact with a particular position. If more than one person will be interviewing each candidate, you’ll have to decide whether to do sequential or group interviews. Although sequential interviews may seem easier, interviewers often obtain more information by interviewing candidates together and observing their responses to all other questions and interpersonal interactions with other interviewers. Either way, the questions to be asked by each interviewer should be coordinated ahead of time. You should write down specific answers and general impressions of each candidate immediately after the interview. It is amazing how quickly your memories of three or four candidates can run together. If you want to use a scoring system to evaluate your candidates, select and list a moderate number of desired attributes (six to 10), ask the interviewers to rate each candidate on a five-point scale, and then total the scores. A scoring system may help to simplify the interview process but should only be used to stratify the candidates. The final selection, which will be from the group of highest scoring candidates, should be based on subjective data as much or more than on objective data.

June 2003

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➤➤ While some questions suggested in the article apply to candidates in any position, others are geared toward specific positions, like administrative staff or nursing staff.

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SPEEDBAR ®

➤➤ Because there are no right or wrong answers in an interview, each practice must choose its own criteria for evaluating candidates’ responses.

➤➤ Avoid questions that focus on personal attributes such as age, religion or marital status, which are illegal topics in an interview.

➤➤ Always ask your candidates if you may contact their previous employers for references in order to get a broader picture of their qualifications.

➤➤ Investing your time in creating quality questions will help you select the best candidate for the job, which will benefit your entire practice.

6. Priority management: “Describe an occasion when you had two doctors or bosses ask you to do conflicting tasks. How did you handle this dilemma?” 7. Work ethic: “Describe a time when your supervisor or a co-worker asked you to help out and doing so required extra work outside your established responsibilities or staying later than you anticipated. What did you do, and how did you feel?” 8. Problem-solving strategies: “Tell me about a time when your job required you to perform a task that you didn’t know how to do. How did you respond?” 9. Response to office politics and gossip: “While at work, a co-worker complains to you about the office manager and some of the office policies and procedures, concluding with ‘Don’t you think so too?’ How would you respond?” 10. Computer competence: “We have a program for [registration, billing, lab result retrieval, etc.] called ____ . Tell me about your experience with that program or programs like it.” 11. Questions for an administrative staff candidate: • “Tell me about your experience handling charges and accounts receivable.” • “You are covering the front desk, and the doctor is backed up. A patient comes in without an appointment and begins describing his symptoms, which could be serious. He asks if he should make an appointment for another time or see the doctor today. What is your response?” 12. Questions for a nursing staff candidate: • “With which procedures are you most comfortable assisting? If asked to assist with an unfamiliar procedure, how would you respond?” • “Tell me about your patient education experiences and in what areas you are capable of educating patients.” • “In what areas are you most interested in receiving additional training?” • To evaluate the candidate’s ability to recognize potential errors: “A normal adult patient calls in with symptoms of a UTI, and the physician writes ‘call in PCN 100 mg bid x 5d.’ What would your next step be?” What’s off limits? A number of personal attributes cannot be legally addressed in an employment inter-

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June 2003

view, including age, religion, national origin, marital status and whether the candidate has children, among others. However, candidates’ answers to some of the questions listed in this article might help you to gauge the impact of certain personal attributes on job performance. For example, the “work ethic”

The last question should always be “May I contact your previous employers for a reference?” question explores availability for extended hours. If you have questions about subjects that are off limits, your attorney or your hospital’s human resources department can offer assistance. Last but not least The last question in any interview should always be “May I contact your previous employers for a reference?” If the candidate says his or her application is confidential and he or she doesn’t want a current employer contacted, at least make any employment offer contingent on these contacts. With the candidate’s permission, contact two or three previous employers or co-workers, and ask the references about the attitudinal issues that are difficult to assess in an interview. These may include patient service, work habits, enthusiasm or any potential weaknesses that might hinder that person’s performance. If the references say they cannot share any information, which might be a red flag itself, a good general question is, “If you had a position open, would you hire this person?” Although this task may be time-consuming, it will give you a much more complete picture of the candidate. In fact, discussions with references are often more beneficial than interviews. Reaching your destination The interview process is a very important navigating tool on your quest to find the perfect staff member. Taking time to define the attributes and skills desired, prepare questions and check references is an excellent long-term investment in the contentment and quality of your entire office. Send comments to fpmedit@aafp.org.