Samuel Kohan: Medical Practice Personnel Management by Samuel Kohan

Guidelines on Staffing Appropriately and What Skills and Experience to Look for in Medical Office Staff Table of Contents Introduction Definitions and Staffing Factors Step One: Medical Office Organizational Type Step Two: Developing Medical Office Organizational Structure i. Centralize or Decentralize? Step Three: Developing Positions i. Leadership Role ii. Management Skills iii. Direct service providers Step Four: Benchmarking, Staffing Levels Step Five: Recruitment i. Employee Interview ii. Job Offer iii. Employment Contract Step Six: Retention Employee Handbook

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Introduction A guide to staffing a medical office can be a simple and short checklist of things to do. However, staffing appropriately is a complex process which demands at minimum an understanding of organizational types, hierarchies, approaches to operating a medical office, strategic human resources management, benchmarking, and employee to physician ratios. This is not to say that checklists are not helpful. There is a checklist in this article that elaborates on important considerations for medical offices engaged in the staffing process. Staffing appropriately can be time consuming and often the expensive aspect of running a medical office. Therefore, it is essential for medical offices not to oversimplify the approach and lend as much time as possible to master the art and science of staffing appropriately. Definitions and Staffing Factors What is “staffing medical office appropriately”? It is the process of selecting and training individuals for specific work within a medical office, and charging them with specific responsibilities. In general, a combination of four factors shapes appropriate staffing in a medical office. Those factors are:

(1) Medical specialty. The type of services that are offered in a medical office may require a specific number of employees for adequate support. (2) Number of providers. Medical providers need adequate staffing to support them in delivering quality services. (3) Patient volume. The number of patients treated on a daily, weekly, monthly, and annual basis. (4) Productivity. The staff productivity in a medical office can be described as the efficiency of production. This is the ratio of staffing to services rendered. This ratio will then reflect productivity. None of these factors may remain permanent in a medical office. As they change, a medical office should be flexible to adapt to change. Step One: Medical Office Organizational Type Medical offices vary in organizational type. Therefore, there cannot be a one-size-fits-all staffing guideline. It would be more practical for each medical office to create a flexible process that actually defines specific staffing actions, than it would be to create a standard process that may have little positive impact. One thing every medical office should recognize is its organizational type. This recognition will be helpful in identifying the staffing needs when positions are developed. A medical office may be categorized under one of the following: (1) Small office – one to five physicians; (2) Medium office – six to twelve physicians; (3) Large office – thirteen to twenty five physicians; (4) Super office – twenty five physicians and more. This organizational categorization which is based on the number of physicians per office is an approximate measurement. It is intended to show that not all medical office organizations are the same and, consequently, they require different levels of staffing and skill sets to operate them. A common issue many medical offices share is the lack of recognition of their organizational type resulting in the failure to identify appropriate staffing needs. For instance, a small office that hires a medical office manager with an extensive background in managing large medical offices may soon discover the manager struggling to perform effectively in a small office setting. The qualifications for a large medical office manager may be very different than their counterpart in a small medical office. A small medical office manager is more of a generalist who wears many hats in a fast paced environment. But, in a large medical office, management’s work is compartmentalized and there are various specialist employees providing support to the management. It is essential to know the medical office’s organizational type prior to embarking on staffing it.

Step Two: Developing Medical Office Organizational Structure What is an organizational structure and why would a medical office would need to develop one in order to succeed in staffing appropriately? Organizational structure of a medical office is where building positions and the task of staffing appropriately begins. An orderly approach to the staffing process can replace mystery with knowledge. Prior to bringing staff into a medical office there should be a framework within which a medical office arranges its lines of authority and communication, and allocates rights and duties. Without an established organizational structure, a medical office may not be able to effectively determine the manner and extent to which roles, power, and responsibilities are delegated, controlled, and coordinated, and how information flows between levels of management and employees. To staff a medical office appropriately, employees should be provided with specific responsibilities in order to perform effectively. In addition, management should maintain consistency in their actions and expectations of their employees. For instance, if a medical office hires a receptionist and fails to communicate the specific expectations to the receptionist, the outcome of the receptionistâ&#x20AC;&#x2122;s work will likely be less than satisfactory. In an actual case, a solo practitioner had a high receptionist turnover problem. Patients complained to the physician that each time they visited his office there was a different receptionist and that they had to get to know new employees on each office visit. Upon a practice assessment by an outside consultant, it was discovered that the line of authority was not clear and employees were not sure whose orders to follow, the physician or the office manager. The physician and the office manager gave conflicting orders to employees. This lack of coordination in the management level and the absence of an established organizational structure created low morale which resulted in high staff turnover and patient dissatisfaction. Often, poor service at a medical office gives the impression to patients that the medical care might be poor as well. Staffing a medical office appropriately requires an organizational structure, a clear line of authourity, and consistent direction from the senior management on a continuous basis. i. Centralize or Decentralize? In a medical office, the leadership should determine whether to centralize or decentralize the organizationâ&#x20AC;&#x2122;s structure. In a centralized organization, the owners of the organization maintain the decision making power and exercise tight control over all employees. In decentralized organizations, the decision making power is distributed and employees have varying degrees of autonomy. A medical office should develop an organizational structure and determine what type of management (centralized or decentralized) it desires to implement. Designing a proper organizational structure, and staffing appropriately, go hand-in-hand.

Sample Scenario Flowchart – Decentralized

Physician (Owner)

External Team: Lawyer, Accountant, IT Firm, Consultant

Office Manager Biller

Medical Assistant

Nurse

Receptionist

Housekeeping

Sample Scenario Flowchart – Centralized

Physician (Owner)

External Team: Lawyer, Accountant, IT Firm, Consultant

Biller

Receptionist

Nurse

Medical Assistant

Housekeeping

Office Manager

Step Three: Developing Positions There are three staffing levels: (i) Leadership; (ii) Management; and (iii) Direct service providers. The type and structure of an organization will dictate development of various positions on each staffing level. For instance, at any given time, a solo practitioner in a small medical office may need to be a leader, a manager, a physician, and perform any other tasks in the office. In mid-level medical offices, physicians tend to hold the leadership and executive management positions in addition to practicing medicine. In a super medical office, physicians often focus on practicing medicine and employees fill all three levels of staffing: leadership, management, and direct service employees, such as receptionists, billers, medical secretaries, and nurses. If we describe leadership as the heart of a medical office, then management is the brain. These roles are of paramount importance in properly structuring and staffing a medical office. Most people believe that they know the meaning of “leader” and “manager”, but here, we will explain their meaning: i. Leadership Role • • • •

An individual who exercises supervisory or management tasks is in a leadership role. When hiring a supervisor or a manager, all elements of leadership should be present. A properly staffed medical office cannot function without an effective and skilled leadership. A medical office leader should possess the following elements of leadership: 1. Character. Put it simply: Treat others as you want to be treated. On going moral support to ensure trust and confidence. Providing moral support ensures trust and confidence. 2. Credibility. An individual in a leadership role should be sincere. Actions and words match values of the medical office. 3. Vision. Influence the future positively. 4. Optimism. Trusting own’s own abilities and that of other team members. 5. Planning. Start each project with the outcome in mind.

6. Communication. Express vision clearly and convey a message that is understood by all. An affective communication requires listening attentively and respectfully to different views and opinions. An effective leader can inspire a sense of being heard 7. Modesty. Lead by example. 8. Courage. Keep the principles, values and vision true. 9. Flexibility. Despite meticulous planning, the course of actions may take a different direction. A leader should be flexible and able to modify the plan to reach the initial goal. 10. Joy. Displays of distress, regret, unhappiness will potentially inflict low morale on others. 11. Diversity. Committed to broadening cultural and social horizons. 12. Empathy. A sense of compassion and responsibility towards others. 13. Winning attitude. Promote a sense of achievement. 14. Continuous improvement. Does not allow himself/herself to be paralyzed by a. failure. 15. Be responsible. Takes responsibility for own actions and does not look for a. excuses. 16. Praise. Nothing will hinder an employee’s productivity more quickly than a a. supervisor who fails to praise a subordinate when credit is due. These criteria should be included in a manger’s job description and revisited on a periodic performance evaluation. ii. Management Skills There is an abundance of office managers to choose from in staffing a medical office, however, finding a skilled and experienced manager may take some time. The reason for so many individuals applying for office manager positions is that most employees think that they can perform their supervisor’s work. In fact, many employees believe their supervisors don’t accomplish much. There is nothing inherently wrong with being ambitious, but there is every reason not to hire or promote an individual to a management position who does not possess all of the essential management skills. What are essential management skills? 1. Financial and accounting management training and experience. A manager does not need to be a certified accountant in order to effectively manage a medical office. Managing an office requires knowledge of accounting principles, and working experience. An ideal candidate with a bachelor of business administration can meet this criterion. Alternatively, a candidate who has successfully completed college level accounting courses may be acceptable depending on the complexity of the medical office and the accounting system in place. In addition to college level accounting training, an office manager should have at least two years of direct experience managing a medical practice’s accounting and finances.

2. Human resources (“HR”) management skill. This is a subject that one can learn rather quickly and take a long time to excel. A medical office manager should be tactful, diplomatic, patient, reliable, trustworthy, and a people person. 3. Operations management skill. It is a must for a medical office manager to be skilled in operations management, which means: optimize productivity. Ideally, a manager is a facilitator who can assist each member of the team in performing their work. This would require the manager to be organized and possess excellent planning skills. For instance, the manager should ensure timely filing of all license renewals, tax payments, permits, payroll cheques, and production of managerial reports. 4. Clinical operations management. Managers with a clinical background are in short supply. If there is a qualified office manager who is also a nurse, he or she would be a very valuable member of the team. Otherwise, an office manager without clinical training and appropriate licensing would need to delegate supervision of the clinical operations to a head non-physician clinician. The manager should have the skills to delegate responsibilities to others and effectively manage the administrative aspect of clinical operations through delegation. This may appear to be simple, but many managers struggle when they have to manage others and delegate using their authority. Another tip for selecting a manager is to avoid hiring and promoting individuals to management positions when they cannot effectively manage through delegation. Micromanagers may find it difficult to manage through delegation. 5. Information technology (“IT”) management. In this day and age, if an individual lacks computer literacy and is not IT savvy, their candidacy for management should be eliminated or placed on hold indefinitely. It is no longer sufficient for a medical office manager just to have basic IT skills. They need to be very efficient and quick to learn changing IT requirements and keep up with new technologies. 6. Risk management. An office manager is responsible in preventing organizational liability. This will require full knowledge of all relevant laws, regulations, and requirements. A manager’s primary role is to monitor performance of his subordinates. Monitoring of employees will reduce cases of theft and neglect. 7. Leadership. A manager should possess leadership skills. Not all leaders are managers, but every manager should be a leader. Effective managers catalyze, stretch, and enhance their team members. Also, an effective manager leads by example. Therefore, leadership skill is a quintessential element of management. iii. Direct Service Providers 1. Nurse Practitioner (“NP”), Nurses, and other licensed clinicians. Fortunately, the licensing authorities have undertaken the responsibility to assess clinical skills and ethics of individuals who receive licenses to render nursing services to the public. Assuming clinical competency of a candidate for a nursing position, the employer should assess the candidates as a productive member of the team with some leadership skills.

2. Medical Secretary. Essential skills for medical assistants include: attention to detail, the ability to work well with others, patient scheduling, medical report transcription, medical records management, medical billing, and an ability to work independently. 3. Billing Specialist. The billing specialist is responsible for managing the information related to OHIP and uninsured billings. He/she has to make sure the patient’s medical visit is accurately coded so that the office is reimbursed accordingly. 4. Receptionist. Generally, receptionists in small offices answer the telephone, make patient appointments, and, often, are the first point of contact with the patients. They should have excellent listening and a verbal communication skill since their job requires intake and providing information to patients. In larger medical offices, a receptionist’s role may be limited to answering the phone and welcoming patients. 5. Housekeeping. Many medical offices outsource housekeeping (cleaning/vacuuming/general upkeep). Administrative staff can be helpful in keeping their work area clean and organized, however, it is advisable to assign them with a general cleaning task. When contracting cleaning services, medical offices should require the cleaning company to produce an updated proof of health care facilities training certificate and liability insurance. Housekeeping staff should not have any contact with patients or work in the presence of patients. Step Four: Benchmarking, Staffing Levels After deciding on which positions best fit your office requirements, the question is how many employees are needed to staff the office appropriately. Achieving an appropriate medical office staffing level is difficult at best. The level of staffing depends on 1. Workload, 2. Processes, and 3. Level of automation. In determining the office staffing level, the following questions should be considered: 1. What are the benchmarks for staffing according to industry benchmarks, which are widely available? 2. How many full-time employees should be assigned per physician? 3. Are staff members keeping up with their workload? (New medical offices should estimate realistic workload for each position. This is not an exact science.) 4. What expectations are set for staff members’ production, if any? 5. How can incentives promote office objectives and motivate staff? For example, if survey results from professional organizations show comparable primary care medical offices are staffed at three to four full-time employees per physician, and your

medical office has eight employees per physician, it might be an indication that your office is overstaffed. Step Five: Recruitment There are several considerations that a medical office should be aware of to ensure successful recruitment of new employees: (1) A comprehensive job description – it helps to achieve a better match between job function and candidates. (2) Beware of first impressions – they do not always provide an accurate picture of the job candidate. Focus instead on the candidates actual skills. (3) Employ only the right individual – not the “next best” even if there are not enough candidates. (4) Use professional recruitment agencies. They can be an alternative solution to the in-house recruitment process. Recruitment agencies can take over almost the entire recruitment process or parts of it. However, using a recruiter has advantages and disadvantages: Advantages: • Time saving • The recruiters usually reach more potential candidates • Recruiters have a lot of experience with searching and finding qualified candidates. Disadvantages: • Cost. • The recruiter may not have enough insight into the medical office staff trends. i. Employee Interview Prior to interviewing a job candidate, a list of questions to ask of each candidate should be prepared. The questions and questioning should not be prosecutorial, misleading, or confusing. The interview is where the future team member is met for the first time, expectations are discussed, and skills addressed. The interviewer should document his/her impression of the candidate during the interview. The main goal of a job interview is to determine if the candidate can do the job. Therefore, the focus should be on assessing the candidate’s skills and qualifications. Also, during a job interview, an employer may question a job applicant regarding possible discrepancies in the resume or the job application. A job interview is an opportunity for the job candidates to describe their skills and qualifications in person and for the employers to assess the candidates’ presentations. However, what makes a job interview very important is not just the opportunity to ask probing questions or to get feedback from the candidate. The interview provides the employer with a venue to observe a candidate’s demeanor and interaction in person and to determine if the candidate is fit and would be a good addition to the organization.

Every job candidate has a unique set of skills and experiences which may require employers to ask questions relevant to the specific candidate and the position at hand. Therefore, there is no standard list of questions to ask candidates during a job interview. However, below listed questions can be helpful with starting a conversation in an interview. • • • • • • •

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Define “teamwork”? What would you consider to be a great workplace? What do you like the most and the least about your current job? Describe your work style? If I called your supervisor what would he/she say about you? Can you commit to work occasional overtime? (Ask this question if the office hours may require the employee to work over-time or irregular hours) Are you punctual? (This question informs the candidate that you will expect punctuality. If it is significant to your office and operations, you should emphasis the expectation of punctuality to the candidate. This is more of a discussion opener, rather than a question that can be answer “Yes, I am punctual”.) Do you complete your work on time? (The same reason as stated above) How do you handle pressure at work? (Under the pressure, some people walk out of office and quit. Some people can get violent or turn to gossip and other unproductive actions in the office. It is important to know how a person handles pressure at work. A good answer can be “I ask my supervisor for support or assistance when I feel overwhelmed by workload.” ) What would you do if you believe your supervisor is wrong about your performance? (Many employees at some point in their career believe that their supervisor is wrong or less qualified than their supervisees. An employee, who does not respect her supervisor or believes that the supervisor makes bad decisions, can cause serious problems in operations of medical office. A good response can be “I would try to resolve my concern(s) by taking them to my supervisor”.) What would you do if you believe your co-workers do wrong? (Some non-manager employees tend to be constantly distracted by what others do and may become constant complainers to their supervisors in the office. This question can be helpful with identifying want-to-be managers who are not being interviewed for supervisory positions.) What kind of support will you need to do your job well? (For instance, a candidate may need additional training to perform a better job.) Why are you leaving your job? (A past performance is an indication of future outcomes.) Can you commit to come to work on time and not to miss work days? (It is only natural that all employees will need to take reasonable time off from work; however, some people are chronically tardy or miss work days more often than others. An employer should discuss with the candidate the office need for coverage and flexibility given to employees who need to miss work.) Why should we hire you? (Allow the candidate to set forth reason(s) for you not to hire others and to hire this candidate) What is your salary expectation?

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Do you have any questions that you would like to ask me? (Always provide an opportunity for a candidate to ask a few questions.)

Practice Tip: Do not interview a job applicant until the applicant completes and signs a job application. You can email a copy of the job application or you can ask the applicant to complete the application when he/she comes to your office for the interview. Why we recommend completing a job application prior to an interview? A standard job application should obtain all relevant and required information from the applicant including the applicant’s consent to verify the information. A completed and signed job application can include and provide legal rights and protections to employers such as permission to conduct background and reference checks. There may be laws that would restrict conducting background checks on anyone including job applicants without the individual’s written consent. Therefore, seek legal advice and ask your lawyer to develop a job application or purchase a job application. Maintain all job applications for a year, if the applicant was not hired. Practice Tip: Not everyone in the office needs to interview the applicant. Job interviews should be conducted by the decision maker(s). You may choose to introduce a promising applicant to other key employees. Practice Tip: An average interview should be about thirty minutes to one hour. Very often, a decision is made within the first five minutes and the interviewer spends the remainder of the interview to find more reasons to support the decision that has been made. Practice Tip: If you are not going to hire the job applicant, don’t continue with the interview, end it and thank the applicant for meeting with you. It is a good practice to inform unsuccessful applicants that another applicant was offered the position, after the successful candidate has accepted. An applicant may not be happy to receive the reject letter or e-mail, but your courteous conduct will provide a proper closure. Practice Tip: Offer a glass of water to the candidate at the interview and remember to smile and be professional. An interview can be stressful and you can help the candidate to relax by showing that you are a friendly person. An interviewer is the face of an organization and can deter or attract qualified candidates. ii: Job Offer Once you determine that a job applicant meets the position requirements, it is time to either make a conditional job offer or a non-conditional job offer. A conditional job offer means that you are offering the job to a job applicant depending on certain conditions. Usually, these conditions would be successfully passing a drug test, passing a criminal and credit background checks, education and license verification, and reference checks. A conditional job offer would allow you to rescind the job offer without facing liability, if the applicant fails to meet one of the conditions you based the job offer upon.

Practice Tip: It is recommended to consult with a lawyer or have a lawyer prepare a document for either a conditional or a non-conditional job offer. Your lawyer can prepare a standard job offer letter so that you don’t have to pay a lawyer each time an applicant is offered a job. Practice Tip: Usually, a conditional job offer is offered shortly after a job interview. It lets a job applicant know that you are very interested in hiring her. If accepted by the applicant, a conditional job offer allows the employer to complete all pre-recruitment requirements. Also, an applicant who does not meet your conditions may not accept the offer which may save you from conducting expensive and time consuming background checks. Practice Tip: Don’t delay making a conditional offer to a qualified applicant. If you deliberate for too long, other medical office may hire the applicant. Qualified job seekers may not be on the market for too long. You may need to take action and make an offer. iii. Employment Contract Generally, a contract is formed when there is an offer, acceptance, and consideration performance. All employments are contractual in nature. It is recommended that all employers create and offer a written agreement to the prospective employee. It is highly advisable to have a lawyer specializing in labour laws and employment to draft the employment contract.

Step Six: Retention Retaining good employees is an important management task, especially when there is a shortage of qualified job applicants. Motivating employees is one of the best ways of retaining them. A few considerations on motivating employee: •

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Employee identification with the medical office's mission and values - employee can see a larger purpose than just his/her job as a career. This can reduce the perception of possible negative aspects of the job. Challenging assignments and stimulating work environment - it is a major motivational factor that employees find their work interesting and challenging. Reward employees - covers both financial and non-financial rewards: salary, recognition, promotion. It is important that employees have a perception that there is consistency between reward and effort. Always respect your employees and supervisees as you would expect them to respect you.

Practice Tip. Common issues many medical office employees report as reasons for leaving a medical office are: (1) below the market rate salary and benefit; (2) lack of job

security; (3) unprofessional treatment by their supervisors; (4) lack of consistency; (5) lack of process; (6) lack of clearly communicated expectations. Employee Handbook When an employee commences employment they should receive an employee handbook. Example of content in the handbook: 1. Administration (recruitment, salary, vacation, pension, etc.) 2. The company's mission, vision and values 3. Development of employees (training, study leave, senior, etc.) 4. Working hours, holidays, absences 5. General employment (retirement, insurance, lunch arrangements, dress, smoking, alcohol, etc.) 6. IT Policy (E-mail and the Internet, send documents using e-mail and Internet for private use, etc.) 7. Other personnel matters (anniversaries, receptions, staff association safety, staffing arrangements, etc.) For smaller medical offices it would be a good practice to seek professional assistance with the administrative tasks.