Managing Staff: That's Not My Job!

The billing clerk worked Tuesdays, Wednesdays, and Thursdays at the solo physician's office. So that meant someone else handled billing on Mondays and Fridays, right?

Not at this North Carolina practice. The clerk and the other employees did not have written job descriptions, and no one else was told to assume billing duties when the clerk was absent.

Todd Frech, a practice management consultant who was brought in to assist the physician in this case, also traced other problems - including seething resentment over uneven workloads - back to a lack of written job specifications.

"When we started looking, we saw that a lot of things that needed to get done on a daily basis were not being done," says Frech. And he found no continuity between the employees who had left the practice and their replacements.

"As people were transitioning in and out of the practice, bits and pieces of peoples' jobs came and went, too," recalls Frech, a senior partner at South Carolina-based Ocius Medical, LLC.

His prescription for this disorder: written descriptions. And yes, he can hear you groaning. "I know that people hate to write job descriptions," Frech acknowledges.

DESCRIPTIONS WORK

But they can lead to a more efficient office and keep you out of trouble in many ways. Written job descriptions can help you comply with federal privacy and security rules and will also hold you in good stead should an employee ever sue you for loss of employment.

In addition, written descriptions could mean increased revenue. More payers are moving to performance-based programs; your job descriptions could include goals for efficiency or customer service for which you are rewarded, such as requiring receptionists to answer calls on the first ring.

Having written job descriptions is not required by law, "but it does make a lot of sense," says Steven Trent, co-chairman of the labor and employment department at Baker, Donelson, Bearman, Caldwell & Berkowitz, PC, a national law firm.

Trent notes that the Americans with Disabilities Act requires employers to determine whether or not accommodations are necessary when a disabled employee or applicant is unable to perform the "essential functions" of her job.

Making such a determination would be nearly impossible without having job duties spelled out, preferably on paper.

"That is the key reason we encourage employers to have written job descriptions," Trent says.

Spelling out employees' duties in some detail is the first step toward making sure they are performing their functions as assigned. Should you later have a problem with an employee, you would be able to document that she knew her job description.

Of course, you would also need to prove that you had offered opportunities for improvement before you took disciplinary action.

Employees who are let go (or applicants who are not hired) because they do not meet essential job requirements are less likely to make successful claims when it is clear what the job's essential functions are, Trent says.

In the same vein, employers should not add duties to an employee's job without her knowledge or without making sure any additional responsibilities make it into the written job description, Trent adds. "You should not inappropriately increase the demands of a position," he says.

Use job descriptions as a way to keep your pulse on your practice's operations. Revise them to correct any problems you may be experiencing.

"Say you are constantly running out of copier paper, or forms for medical records. Why is that? Well, maybe no one is responsible for those activities," says Frech.

INCLUDE HIPAA DETAILS

Job descriptions also should include details about who has access to what for HIPAA purposes.

For doctors' offices, the most relevant areas of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 deal with electronic transactions, privacy, and security.

The privacy rule, which has been in effect since April 2003, and the security rule, which was implemented April 2005, apply to physicians and other healthcare providers. In broad terms, the privacy rule requires safeguards to protect oral and written health information, while the security rule covers patient data that are transmitted and stored electronically.

The privacy rule states that covered entities can share information without patient authorization for purposes of "treatment, payment, and healthcare operations." But it also specifies that information that is shared between covered entities must be limited to the "minimum necessary" that a person needs to do her job. That means, for example, that a staff member who makes appointments doesn't generally need access to the doctor's notes in a patient chart.

To comply with the privacy rule, you should spell out within job descriptions which type of patient healthcare information the employee needs to access within her responsibilities.

Similarly, the security rule mandates that covered entities develop systems for controlling access to patient health information.

One way of doing this suggested by the rule is to permit "role-based access." Spell out in your job descriptions what each worker can access, how the worker accesses the electronic information she needs (such as with a unique user log-in), and establish systems that block inappropriate access once the user is viewing patient medical records or other relevant databases.

"If the medical assistant is the biller and also helps with the medical record, obviously that person is going to have full access," Frech says. "But the receptionist may have access to a limited amount of protected health information. That's what would be defined in the job description. ... Having clear job descriptions makes the job of deciding who has access to what information a lot easier."

Making these kinds of judgments, Frech says, is akin to other risk management activities a practice performs, such as complying with federal workplace safety requirements. "Many of my clients also put a familiarity with HIPAA in job descriptions as part of the performance evaluation criteria. This is not a HIPAA requirement but just good practice," Frech adds.

PICTURE THE PATIENT

If you don't already have job descriptions for your staff, don't fret. One way to begin is by picturing yourself as a patient in your practice, says Frank Ruelas, a compliance officer for the Gila River Health Care Corporation in Sacaton, Ariz.

Gila River includes a 12-bed hospital and a large outpatient clinic. The clinic has 19 physicians, three physician assistants and six nurse practitioners. In addition, there are 24 administrative personnel, including five appointment clerks and six billers and coders.

Ruelas recommends that practices build a flow chart that begins with a patient coming into the practice. Who are all the people the patient meets? What happens at each encounter? This process can help identify the major duties of each person with whom the patient has contact.

You might also see where there are gaps in duties. You might discover, for example, that no one is responsible for periodically updating your Web site. "We just did a reorganization of our entire outpatient department, and we found several instances where we realized certain things were not being done," Ruelas says.

"You could also take a look at getting payment, or getting paychecks done," says Frech. "What are all the things that need to get done? The next thing is to dole those responsibilities out and make sure that the primary [tasks] will be done. And identify who will take them on if the primary person is not available."

Ruelas suggests that whenever possible, individual supervisors write job descriptions for the people who report to them, as they have the most intimate knowledge of those job duties. "That could be the office manager or the nursing supervisor for clinical staff," he says. If you choose to have job descriptions for physicians, you should have another physician write them, adds Ruelas.

However, if your group is large enough to have a human resources or personnel department, someone from that area should review all the descriptions for consistency.

For example, you may wish to require that all physicians hired be board-certified. If that is not the practice's policy, it probably should be listed as a job requirement.

Be sure that job specs are current. You may need to make changes when you buy a piece of medical equipment or implement new technology, such as an electronic medical record system or a new practice management system. Eliminate duties that are no longer necessary or relevant and assign others that are currently required.

Finally, if you conduct annual performance evaluations of your employees, use this opportunity to review their job descriptions to determine if they are still accurate or should be modified. Pointedly ask the employees what they think.

"Our job descriptions are seen as implied contracts between the employer and the employee. As the job develops, people sometimes become aware of what was not included in the job description," Ruelas says. "Without written job descriptions, there is no ownership of responsibilities."

Theresa Defino, editor for Physicians Practice, can be reached at tdefino@physicianspractice.com.

This article originally appeared in the April 2006 issue of Physicians Practice.