Improving Medical Practice Staff Performance and Productivity

Selma Vaughn manages two primary-care practices made up of three physicians, two nurse practitioners, and 20 staff members. Over the nine years Vaughn has worked at the practices, she has seen her fair share of staff turnover, changes, and challenges. One thing she's learned: Teamwork is crucial to forming a positive and productive staff. "You have to have it 100 percent," says Vaughn, whose practices are located in Richmond and Glen Allen, Va., and are part of the Bon Secours Health System. "You need your team to work well - you need them to work well together, and you need them to work well with the physicians."

To that end, Vaughn works hard to ensure staff members are working together - and working to the best of their abilities. She checks in with them frequently, runs reports to monitor performance daily, and asks staff to huddle each morning to discuss potential problems that may arise during the day. "You're trying to get ahead of anything you think might be an issue or cause any type of backup in the schedule," says Vaughn. "I have conversations with them and I try to do different things to motivate them."

Like Vaughn, physicians and administrators across the country are working hard to boost staff performance and productivity. But it's not easy. Staff members are already stretched thin as practices operate with smaller staffs due to declining reimbursement and increasing overhead. Plus, at many practices, staff members face mounting pressure to increase visit volume. That's leading to high rates of clinical and administrative staff turnover at many practices. In 2012, for instance, the turnover rate among physician assistants and nurse practitioners at medical organizations was about 12 percent, nearly double the rate of physician turnover, according to the 2012 Physician Retention Survey from healthcare professional recruiting firm Cejka Search and the American Medical Group Association.

Luckily, experts say there are many ways practices can better retain staff members while boosting their performance and productivity. We asked administrators and consultants to weigh in on this subject. Here's what they say your practice should do to make the most of its staff.

Finding the magic number

Right-sizing your staff is critical as reimbursement declines and overhead increases. One staff member too many could push your practice into the red, one too few could lead to backlogs and high turnover. Industry benchmarks, such as those included in the Medical Group Management Association's cost survey reports, provide average physician-to-staff ratios by specialty. Consulting such benchmarks can help you determine if your practice's staffing numbers align with other similar practices.

Still, don't adhere to benchmarks too strictly. The ideal staffing number for a practice varies depending on several factors, including reimbursement model, technology acquisitions, and even the physicians within the practice. Some physicians, for instance, are more productive if they are working with two or three medical assistants (MAs), while others are "gangbusters" with just one, says medical practice consultant Charlene Mooney of the Halley Consulting Group in Columbus, Ohio. Similarly, a practice that has acquired the newest technologies may have different staffing needs than one that has not, says Karen Zupko, president of Chicago-based practice management consulting and training firm Karen Zupko & Associates.

When determining if your staff is the right size, in addition to benchmarks and your practice's unique characteristics, consider your goals and priorities, says practice management consultant Owen Dahl. For instance, if increasing visit volume is a big initiative, an additional receptionist may be appropriate, and if you are adding ancillary services, you may want to add staff as well. "It really depends upon the driver of the type of practice you have, and then the type of services and volume of patients that you would have in the practice," says Dahl.

Identifying responsibilities

Ensuring your staff members have the right roles and responsibilities is just as important as finding the right staffing numbers. Problems that arise when responsibilities are not clearly defined can include focusing on a task that someone has already completed, failing to complete a task because you believe it is delegated to someone else, and focusing on a task for which the staff member is over- or under-qualified.

While it sounds simple, strong job descriptions can help counteract and prevent these issues, says Dahl, noting that even if your practice already has job descriptions in place, it may be time to reevaluate. "I would interview and talk with the staff and find out: 'Is the job description that I have appropriate? Is it too broad?' And then if that's OK, 'Have we done the right training? Do we have the right tools?'" says Dahl. The latter is especially crucial to ask as new technologies emerge. For instance, automated insurance verification or online appointment booking might help front-desk staff spend more time interacting with patients when they present for appointments. "You've got to really drill down to figure out what they are doing and if there are any tools and techniques that may be available to help with that process," he says.

Allocating responsibilities

While strong job descriptions ensure staff members know their responsibilities, an operations manual helps them understand how to fulfill those responsibilities. An operations manual should list each task that occurs in your practice, identify who is primarily responsible for it, and very specifically state how it should be completed, says Carol Stryker, founder of Houston-based medical practice consulting firm Symbiotic Solutions.

If practices lack such a manual, productivity and performance suffers, she says. "Because it's not real clear who's responsible for something, or maybe people are responsible but they don't do it and there's no consequences for it, there ends up being a relatively high level of mistrust in the office," says Stryker. "The effect … is that sometimes the work gets done two or three times. Maybe Sally is supposed to be calling patients with lab results - but I know Sally's not real faithful about that - so Sally calls with lab results, and then I go back later in the day and look to make sure she's [done that]."

An operations manual helps eliminate those issues because it's easier to hold staff accountable when they don't perform properly, says Stryker. "You have an objective definition of what's expected and that helps train the staff, it helps keep the staff on track, and it allows the physician to fairly hold them accountable."

For Stryker's tips on creating an operations manual, visit http://bit.ly/Ops-Manual.

Holding staff accountable

One of the best ways to hold staff accountable is by addressing issues as soon as they occur, says Stryker. For example: If a physician enters an exam room and finds that his MA has not taken all the patient's necessary vitals, he should immediately exit the room and ask the MA to complete the task properly. If the physician instead completes the task for the MA, the MA's behavior will not change and this will become a repetitive issue, says Stryker. "Sometimes it's worth going a little slower and maybe even falling behind to make the point about what it is you expect and get the behavior you want."

On a more long-term basis, hold regular performance reviews to ensure staff members are held accountable and know what they need to improve. Practice manager Sharon Grosscup, who recently joined Coshocton Hospital Orthopaedic Clinic, a two-physician practice in Coshocton, Ohio, holds monthly performance reviews with staff. After Grosscup and the staff are more accustomed to working together, she plans to hold performance reviews less frequently, perhaps every six months. The evaluations serve two purposes, says Grosscup. They hold staff members accountable, and they hold her accountable. "I'll ask them, 'Is there anything that you need from me to help you do your job better?'" she says.

If staffers fail to perform properly despite repeated attempts to fairly evaluate their behavior and correct their mistakes, "Get rid of them sooner rather than later," says Stryker. Poor performers are a drag on overall morale and productivity, and retaining them could make it difficult to keep your highest performers. "If I'm doing a good job, and my reward for doing a good job is I have to do my job and somebody else's too, that doesn't make me want to stay there," says Stryker.

Improving performance

In addition to holding performance evaluations, engage in goal setting with your staff. That way staff members will not only work to maintain their performance, they will also work to improve it.

Frame goals around positive changes you would like to see occur in your practice, says Mooney, adding that goals can be practice-wide and/or specific to individuals. For example, if a staffer needs to be more punctual, her goal could be: "I'm going to make an effort to be on time every single day."

If instituting a practice-wide goal, break it into specific, measurable goals that can be tied to action items, says Zupko. For instance, if the overall goal is to improve collections, ask front-desk staff to increase time-of-service collections by 20 percent.

Always provide incentives for meeting goals, says Mooney, adding that even small treats, such as a pizza party, a thank-you card from the physicians, or a certificate of achievement, are great motivators. If money is tight, consider offering time off or flex time, says Dahl.

*For more creative incentive ideas, visit http://bit.ly/staff-boosters.

Broadening skills

Perhaps one of your staff members would like to help manage an EHR implementation, or a receptionist has marketing experience and would like to craft an e-newsletter. You never know until you ask. If a staffer expresses an interest in something new and your practice can cultivate that skill, the staffer will become more engaged and productive, says Mooney, who recently worked in a practice where an MA wanted to get involved with referrals and prior authorizations. Providing the MA with the training to take on the new role boosted her commitment and engagement, and it benefited the practice because her clinical knowledge helped streamline the referral and preauthorization process, says Mooney.

When attempting to broaden staff members' skills, consider sending them to conferences, seminars, and courses. But your practice itself is a great education-development hub. Mooney suggests instituting a mentoring program to encourage staff to help each other develop new skills. A nurse mentoring an MA, for instance, can help the MA hone her skills and explore new ones, while a receptionist mentoring an MA can share her customer service and communication skills. Also identify areas where staffers shine, and foster those skills, says Mooney. For instance, if an employee is financially savvy, ask her to find a better and cheaper medical supply vendor.

Fostering collaboration

Mentoring also ensures staff members are supportive of each other, which helps foster teamwork. As Vaughn pointed out, this is critical to creating a positive and productive staff. Here are some other ways to foster teamwork:

Cross train. At practice administrator Donna Kreuter's four-physician practice, Women's Care Center of Columbus, front-desk staff receive training on every aspect of check-in, check-out, and reception. "We really need people who can jump in and go from one window to another," says Kreuter, whose practice is based in Gahanna, Ohio. "If one work area is busier than another then they get that support."

Don't play favorites. Make sure physicians and leadership treat each employee according to the same standards and expectations, says Mooney. "That makes everyone feel an equal part of the team and it [ensures] that there's no resentment there."

Solicit input. Ask staff members to share their improvement suggestions and input. Kreuter does this frequently at her practice, especially when embarking on a new project, such as the practice's EHR implementation. Asking for input fosters engagement and creates an "ongoing culture of cooperation," says Kreuter.

Keep it positive. Make it clear that negativity and gossip are not tolerated at your practice, says Mooney. "We have to be able to work together, we have to support each other, and we have to be positive with each other."

Right-sizing

Industry benchmarks are a great way to determine if your practice's staffing matches up to other similar practices. To help you get started, here are some of the median findings from the Medical Group Management Association's (MGMA) "Cost Survey for Multispecialty Practices 2012 Report Based on 2011 Data" for all multispecialty practices. The full report is available for purchase through the MGMA's website.

• 0.30 nonphysician providers per FTE physician;

• 1.07 business operation staff per FTE physician;

• 1.46 front-office support staff per FTE physician;

• 1.63 clinical support staff per FTE physician; and

• 0.54 ancillary support staff per FTE physician.

For more benchmark reports, including those that are specialty-specific, visit the MGMA's website.

Efficiency tip

When staff members are interrupted while completing a difficult task, it takes them twice as long to finish it, and they make twice as many mistakes, says Carol Stryker, founder of Houston-based medical practice consulting firm Symbiotic Solutions. Keep that in mind when delegating staffing roles and responsibilities.

For example: If a staff member is working on something complex, such as obtaining preauthorizations, ask her to do so in a quiet area. On the other hand, if a staff member is responsible for a fairly simple task, such as answering phones, ask him to multi-task, e.g.  addressing envelopes during downtime.

In Summary

During tough times, it's critical to ensure your practice is making the most of its staff. Here's how:

• Make sure your staffing numbers align with practices of similar specialties.

• Craft strong job descriptions outlining staff roles and responsibilities.

• Create an operations manual that addresses responsibilities within the practice.

• Equip staff with the necessary tools and training.

• Evaluate staff performance and hold staff accountable.

• Encourage goal setting, mentoring, and delegating to broaden staff members' skills.

• Foster teamwork by cross training, discouraging gossip, and treating staff fairly.

Aubrey Westgate is an associate editor at Physicians Practice. She can be reached at aubrey.westgate@ubm.com.

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