After a long eight years, unemployment has declined to near pre-recession levels. But, also during that time, the healthcare industry has significantly shrunken its footprint — reducing medical staff in response to downward market forces and declining reimbursements. For many small independent practices, that means doing "more with less," a mantra they have been embracing for several years.
Susan Apold is an adult nurse practitioner who has practiced for 18 years as part of a small, solo-physician practice in New Rochelle, N.Y. It is the type of practice she likens to the fictional medical practice of Marcus Welby, MD. "We know our patients, we know their history, they have been with us for many, many years, and are doing quite well," says Apold. Yet, low reimbursements and limited staff and resources to invest in billing and coding hamper the practice's financial viability, she says.
"[In] this practice there has been a lot of conversation about whether this is a sustainable model, because [other local physicians] were selling their practice and joining larger groups," she says. But the practice survives, Apold adds, in part due to her ability to see her own patients and free up the physician to bring in additional revenue — through seeing hospital and nursing home patients.
Your practice likely struggles with the same issues. To help, we asked our experts to tell us how smart staffing can help a practice become more productive and efficient. Here's what they said.
BUILDING A STRONG FOUNDATION
In our seventh annual Physicians Practice Staff Salary Survey, we heard from 1,066 physicians and practice administrators nationwide. The majority still say they are in a traditional, fee-for-service practice. Seventy-six percent of respondents employ one to five physicians. And43 percent of respondents say they made no changes to their staffing levels over the previous year, while 32 percent say they increased workload without increasing salary. Add to that fact, two-thirds of respondents say they have not given their staff annual raises, except to cover the cost of living, and you have a rather dismal picture for staff.
To stay solvent, that means practices need to work smarter, and refine staff roles so that all employees are working to the top of their license. Practices must also become more efficient, eliminating redundant tasks, and training staff to take on more complex roles. That sounds like a tall order, but if you break down the tasks into smaller steps, you'll be amazed at what you can accomplish. Here are a few places to start:
• Hire right, the first time. Charlene Mooney, a consultant with management firm Halley Consulting Group, says one of the worst mistakes that practices can make is to "hire the first person off the street," because they are in a rush to staff an open position. Very often that strategy backfires, as a poor hire can cost the practice time, money, and flagging staff morale. Mooney advises practices to review potential candidates closely and always involve physicians in the interview process.
• Let staff work to the level of their license. Having worked her way up through the ranks as a staff nurse and clinical manager, Liz Yankello has served as practice manager at Sewickley Valley Pediatric & Adolescent Medicine (SVPAM), based in a suburb of Pittsburgh, for the past 15 years. She says the practice culture at SVPAM is a bit unique because the physicians "want to support staff to be knowledgeable, and to use that knowledge in the office setting to the best of their ability." In practice, that means staff members are allowed to take on greater responsibilities for patient care; albeit within the scope of their medical license.
• Find the right number of staff, for the right role. Consultants will tell you that the most effective practices have greater staffing ratios. So does SVPAM. "We are one of the only practices [in our area] that consistently has an RN staff or [a licensed practical nurse (LPN)] staff," says Yankello. In fact, SVPAM staffs seven RNs, four LPNs, and two advanced practice nurses, along with three certified medical assistants to "work adjunctively" with the nurses. Yankello says the cost of employing nurses more than recoups itself by allowing the physicians to see more patients, and be more effective in their care. For example, the "check-in nurse" collects vital signs, family and social history, developmental history, dietary history, the chief complaint, etc., and enters that data into the EHR before the physician even sees the patient.
• Employ advanced practitioners. Advanced practitioners are a hot ticket nowadays; over 60 percent of our survey respondents said they employ at least one NP or PA. It makes sense. Apold says that there are a number of advantages to working with an NP. "You have increased [patient] volume, physicians are free to do the work they were trained to do, [and] practice at the top of their licenses, and it ultimately generates more money for the practice," she says.
SMART MANAGEMENT STRATEGIES
When we asked our survey respondents what their greatest staffing challenges were, they said lack of staff training/subpar skills; lack of professionalism among staff; conflict among staff; and low staff motivation. With the exception of staff training, the rest of these problems can be addressed by communicating clear job expectations, conducting frequent staff reviews, and prompt remediation for lagging staff, says Mooney. Here's how to approach each of these areas, and a few more to ensure your staff is happy, motivated, and efficient.
Good communication is vital to good job performance. Most managers would tell you this. But in the hurly-burly of daily practice, it is often forgotten. So too are employee job descriptions. But, if an employee does not have a clear idea of what is expected of her, how can she do her job well? Mooney says that she frequently finds job descriptions missing. "I say to a manager, 'How can you write someone up when you haven't told them what's expected of them?'" Mooney recommends letting staff know what's expected of them; holding them accountable for their performance; and if necessary, addressing poor performance promptly. Bad attitudes and sloppy performance will negatively affect the rest of your staff; they can even contribute to losing top staff members. Mooney says she has no problem getting rid of a problem employee. "I see offices let things go on, either because they are afraid to lose the person, or the person has been there a long time, or is a friend of the manager," she says. "But when you have a problem employee … it is very bad for morale."
Declining reimbursements mean less money to compensate existing staff, and to hire new staff. Therefore, practices must utilize staff to the top of their license, and create processes to maximize efficient operations. Here are key areas to watch:
• Hire right the first time.
• Provide staff with clear job expectations.
• Give frequent praise and feedback.
• Consolidate tasks to increase efficiency.
• Use a team-based approach to patient care.
Performance reviews are not always a favorite among employees, but done well, they are instrumental in achieving stellar performance. Mooney says that periodic get-togethers, two to three times a year, are better than just one annual meeting. That gives the manager and employee a chance to discuss what's going on in the practice, and address areas that may pose problems. Even a simple, "How are you doing?" and, "Do you have any ideas on how we can improve?" can work wonders for enhancing work flow. Taking that concept a step further, Mooney likes to promote what she calls a "critical incident appraisal." That could mean on-the-spot kudos for an employee who was especially helpful to a patient, or talking to a chronically late employee. She says managers shouldn't forget to put a brief note in the employee's file, so that information will be available during the annual review.
Deborah Walker Keegan, president of healthcare consulting firm Medical Practice Dimensions, Inc., says the current trend in staffing models is flexibility. "We are really trying to staff a process and not be so people dependent," she says. "There is a lot more cross-coverage and cross-training, and multi-tasking of the staff; particularly in the smaller practices …" Walker Keegan recommends having a "super-trained" staff member of the team who can handle a number of tasks when another person is out sick. So, for instance, a medical assistant can not only work in the back with patients, but also "work the front desk, manage the telephones, and conduct check-out," when necessary, she says.
Many times, practice work flows grow up through necessity, not by planning. They can sometimes become ungainly, and absorb more time than they really should. One concept that Walker Keegan recommends is to take a look at the number of "desks" you have in your practice, and eliminate those that are unnecessary. By this she means taking a look at the number of tasks that happen during the patient visit, and consolidating as many as possible in a single location. She suggests letting the MA appoint patients for routine follow-up appointments while they are still in the exam room; thus eliminating the need for the patient to queue at the check-out desk. Walker Keegan says that this type of streamlining reduces the number of desks that need to be staffed, and "is a delighter for patients who don't have to travel throughout the practice. The work is brought to the patient …"
Busy physicians can be so focused on patients that they fail to let their staff know they are appreciated. But thanking staff isn't just about being "nice," says Mooney, it is vital to retaining your best staff members. "I found that it is not just what you pay someone, it is how they are treated [that incents staff to stay]; how they feel, are they part of the team, how are they motivated, valued, and appreciated," she says. And don't worry; appreciation can come in small packages. Mooney says it can be something as simple as ordering pizza for an impromptu lunch, or greeting staff members personally in the morning. Yankello says each of the staff members at SVPAM gets a gift on her birthday, every year. "We sent them to a spa one year. This year they got an extra half-day vacation day," she says.