Reducing Medical Practice Staff Turnover

Trim the fat from operating expenses all you like, but if you can't seem to stem that elusive leak in your budget you might try focusing on the revolving door to your practice instead. Offices that experience poor staff retention often get stuck spinning their wheels, unable to reconcile higher recruiting costs with lackluster productivity. Indeed, employee turnover is an insidious drain on resources - far more than most managers believe, says Donna Knapp, an independent consultant with Medical Group Management Association Health Care Consulting Group. "You lose a lot of tribal knowledge each time someone leaves," she says. "Even if they train their replacement, there's inevitably something lost in the translation." That might be the relationship they built with a patient, or something more subtle, like how your physicians like things done or the history behind that unresolved invoice. Never mind the toll it takes on morale when your remaining staff is overburdened, or the inevitable mistakes that occur due to inexperience when a new recruit is brought up to speed. "It all impacts consistency of performance," says Knapp.

Managing turnover is all the more critical in the current healthcare environment in which Medicare and many private insurers factor patient satisfaction scores into their reimbursement calculations. Patients value a staff that greets them by name, or remembers that they like their prescriptions electronically sent to a specific pharmacy. That's tough to achieve when the faces in your office are always in flux. "Medical practices need to maintain a personal relationship with their patients, so when your medical assistant leaves that connection disappears," says Knapp. "It's not like going to Macy's where you expect a different clerk to assist you every time."

Retention of clinical staff, in particular, is also playing a greater role as medical groups increasingly adopt provider team models, such as the Patient-Centered Medical Home, in which a group of providers works together to improve continuity of care. Yet, for many practices, it can be hard to hang on to nurse practitioners and physician assistants. A 2011 Physician Retention Survey from Cejka Search and the American Medical Group Association found a turnover rate of 12.6 percent for both nurse practitioners and physician assistants, more than twice the combined, adjusted physician turnover rate of 6 percent. "The implication from these findings is that forming and maintaining care teams - especially in primary care - will be among the industry's most significant challenges," the report notes.

Check your pulse

To boost your retention rate, you first need to find where you stand. You can calculate your turnover rate by identifying the percentage of your staff that has left your practice over the last five years, says Judy Capko, owner and medical practice consultant at Capko & Company. A loss rate of 15 percent or less is reasonable, she notes, while anything approaching 20 percent or more is too high. The final number, however, can be deceiving. Look beyond the percentage for any patterns that may emerge. You may, for example, have a 10 percent turnover rate overall, which wouldn't appear problematic except that it's all coming from your accounting department or nursing staff. It's time to find out why. Perhaps the supervisor micromanages, the workload is unreasonable, or staff lack the tools necessary to succeed. The only way to find out is to ask.

Employee surveys are an excellent way to take the pulse of your practice, says Gerrit Salinas, director of medical staffing for Dallas-based staffing agency Snelling. "Depending on the size of your organization you should survey your employees quarterly or twice a year," he says. "Compile the data you receive and share with the workforce what you've learned." You need not promise a solution right away, he adds. It's really about acknowledging their concerns. "Let them know that you don't have an immediate solution and invite them to offer suggestions so they are part of the process," says Salinas. Exit interviews, where managers interview departing employees, are another chance to solicit feedback on what you could be doing better. Not surprisingly, employees who have already tendered their resignation are often more candid in their appraisal.

As you address their concerns, however, don't let fear of mutiny dictate your decisions. Use employee feedback as an opportunity to help your office work smarter, says Kenneth H. Cohn, a practicing general surgeon and CEO of Healthcare Collaboration, which works with providers to improve financial and clinical outcomes. "When you hear someone say, 'We need to hire a new FTE [full time equivalent],' that's a good time to see if there's something you can do in the moment to help make everyone's time count," says Cohn. Look at the job description and have relevant staff members make a list of their responsibilities step-by-step on separate Post-it notes. Put each responsibility up on a wall and step back. "Suddenly people start moving the Post-its around and interacting about how the process works and how it could work better," says Cohn, noting one of his clients, a medical group in Indianapolis, used the Post-it note system to eliminate 23 non-value-added steps for a team of providers administering insulin to patients, which resulted in lower costs, better safety measures, and improved outcomes.

Likewise, says Salinas, take the time to assess staff member's personalities and skill sets to be sure they're a good fit for their posts. A numbers-oriented employee will not last long checking patients in at the front desk, just as an outgoing people person won't be satisfied staring at a computer screen all day. That's true, too, in many cases, of the rapport between employees and their supervisors. "You may have hired an employee who doesn't match the culture that their manager sets," says Salinas. "It doesn't mean he's a bad employee, or that the manager is a bad leader. You just need to be sure that your workforce mirrors the attitudes and behaviors that their supervisors are looking for." Before you incur the expense of firing and hiring another employee, he says, try shifting that person to another department where he may be more likely to thrive.

Culture of caring

Your ability to inspire loyalty, of course, is only as good as your culture, notes Cohn. Management must invite employees to air grievances as they arise, inspire them to take ownership of their jobs, and remind them continually that their contribution matters, he says. "Turnover is a problem that is much better dealt with by avoiding or preventing it than by treating it," he says. "Doctors need to create a climate of safety which encourages people to reflect on and process issues so they can move on." When employees feel disenfranchised, he notes, it leads to lower morale, reduced productivity, and ultimately resignations.

Try, too, taking your staff to lunch after they meet certain goals - like consistently answering the phones in three rings, helping to raise patient satisfaction scores by 5 percent over the last quarter, or accommodating one extra patient per day for the last month. Gift cards for employees who go the extra mile or keep a smile while dealing with a difficult patient are inexpensive ways to recognize employees for a job well done - and reinforce the professionalism you value. It's the little things that make your employees want to show up every morning, says Knapp. Say hello when you walk in the door. Model good manners for others. Thank the staff member who helped on a project when no one even asked. And do it in front of their peers. "Creating a culture of kindness is essential," says Knapp. "A lot of people leave because they're not happy with the people around them. Make sure you recognize all the good that goes on in the office."

It need not involve compensation, but it's also important to recognize employees who have made a commitment to your practice, says Salinas, thus sending a message to their peers that you value loyalty. "I'm not a big believer in increasing pay based on tenure, but I do think loyalty rewards can be very beneficial," he says. "What's wrong with a five-year watch or plaque to put on the wall to recognize loyalty?"

Get creative

In the quest to boost retention levels, competitive pay is a given, but practices with the highest levels of employee satisfaction also help breed loyalty by offering perks that make it hard to leave. For many, that means flexible hours, allowing employees to work four 10-hour days, or work from 6 a.m. to 2 p.m., where practical. "Staff members who deal with patients, of course, need to be there when patients are scheduled, but those in your business office may be able to have less traditional hours," says Knapp, noting her office allows flextime as long as the employees get their work done and make themselves available for meetings. Other practices offer employee discounts on procedures or products, free gym memberships, free parking, half-day Fridays during the summer months, tuition reimbursement, or an all-expenses-paid family day at an amusement park. Managers are limited only by their imagination.

Staff development

Practices that hope to keep their best and brightest engaged must also encourage professional growth by offering offsite training, designating their most competent employees to bring new recruits up to speed, offering time off for relevant coursework, and cross-training their team, says Salinas. Also try bringing one or two staff members with you to networking events, and rotating whom you send to seminars offered by your professional organizations. Not only are such moves a vote of confidence in employees' abilities, but they also benefit your practice when employees report back to the rest of the staff what they learned.

And don't forget to groom from within. For example, at Trinity Mother Frances Hospitals and Clinics - a group of 275 employed physicians in Tyler, Texas - physicians and nonphysician providers are invited to hone their leadership skills twice a year. "When I interview people on the front end, I talk to them about opportunities and try to get them to contemplate being engaged in some leadership role, even a low-level leadership activity beyond the practice of medicine," says Gregory Stovall, an internist and senior vice president of medical affairs and organization development for the group. "We formalized that into a leadership academy where we have one-day workshops in the spring and fall." Once someone assumes a leadership role, he notes, "it builds loyalty to that organization."

Hire right

When combating high turnover, a robust hiring process is half the battle. It's a lesson that Trinity Mother Frances Hospitals and Clinics learned the hard way. "In our early years we were recruiting aggressively because we wanted to grow our specialties and grow geographically, but then we began to do some analysis and discovered our turnover was fairly high," says Stovall. "It was extremely expensive and we decided that if we could improve our retention it would have a dramatic effect on our financial performance."

The group, which cut its turnover rate to less than 4 percent, created a committee to improve retention through a series of initiatives that started with creating a partner profile. The document identified the personality attributes that Trinity was seeking from new providers. "We defined much more clearly what we were looking for in future partners including collegiality, competence, character, and commitment - all the character traits you don't get from a CV," says Stovall. Once hired, the committee assigns an existing provider to act as a mentor, helping each new hire acclimate more quickly to the corporate culture and address any issues before they become reasons to leave. The group also asks a provider's spouse to reach out to the family of the new provider. "We recognize that when we recruit someone new we recruit their whole family so we have spouses here who reach out and contact the new physician's spouse before they even arrive to welcome them and offer advice on where to shop and send their kids to school," says Stovall.

Indeed, efforts to retain new employees for the long haul begin on day one - especially for higher paid providers who take longer and cost more to recruit, says Stovall. All healthcare providers in his group enter a formal orientation program to help indoctrinate them into the company culture faster, an increasingly popular concept in human resources management known as "onboarding." "We really try to clarify the vision, mission, and values of our organization," says Stovall. "We also educate them a bit on the history and heritage of our group."

Continuing education is an important part of the retention plan at Cleveland Clinic as well. The nonprofit multispecialty academic medical center provides a leadership, education, and management curriculum for staff, residents, fellows, academics, nurses, medical students, and administrators. "We are committed to making sure those who join us are onboarded correctly so they attain a sense of our culture, history, and strategic plans to help them get off to a stronger start," says Caryl Hess, director of the Cleveland Clinic Academy, noting turnover at the Cleveland Clinic is "well below" the national norm. "Research shows internally and otherwise that people who are brought into an organization correctly and feel engaged and satisfied are more meaningful contributors. It's only natural that they'll stay longer and continue to be contributors."

Some turnover, of course, is inevitable. The best run practices anticipate that and prepare, says Knapp. "Have a solid orientation and training program in place so each new person can drop into that job at any time with minimal disruption," she says. "Make DVDs that define the company culture, create written policies on work flow, write job descriptions for each position - anything that helps them do their job faster and better." Those that take the time to hire right, develop their staff, and reward for work well done will not only minimize the costly effects of turnover, she says, but help keep the talent they have both present and productive.

In Summary

Losing medical practice staff is inevitable, but there are some things you should keep in mind and address proactively to avoid losing precious resources:

• Turnover affects both staff productivity and patient satisfaction.

• Managers who recognize and reward staff members breed loyalty.

• Surveying employees often helps managers take the pulse of their practice.

• Offering perks, like flextime, makes it harder to leave.

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 18 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via editor@physicianspractice.com.

This article originally appeared in the March 2013 issue of Physicians Practice.