In Practice: Intra-office Tug-of-wars

There’s a war raging at doctors’ offices across the country and it’s not for the reason you think. Indeed, while it’s easy to blame insurance providers and regulatory agencies for turning the healthcare industry on its ear, the most common source of contention comes from within: the friction that exists between front- and back-office staff.

From nurses who snap at schedulers for double-booking patients, to billing clerks who gossip about the “overpaid” medical assistants, the us-versus-them mentality at many practices is rampant. “It’s a common problem,” says Fran Lavallette, facilitator at Healthcare Facilitators consulting firm in Orlando, Fla. “It’s a very disjointed relationship - almost like having two separate departments.”

And it’s not just a matter of driving down morale. Eventually, division among the ranks leads to work flow problems, high turnover and low levels of productivity - not to mention the palpable tension that drives patients straight out the door. “The blame game is the worst thing that can happen,” says Charles Sodikoff, a psychologist and organizational consultant in North Merrick, N.Y. “When everyone’s pointing fingers at everyone else, it really turns off the patients.”

Mar vs. Venus

Part of the problem is that the responsibilities of the front- and back-office staff are so vastly different, it’s hard for them to relate to one another. Front-desk clerks are charged with answering phones, managing the schedule, collecting copays and registering patients. The clinical staff, including nurses and medical assistants, work side by side with the physicians, prepping exam rooms and assisting with patients.

“Medical assistants have an opportunity to be one-on-one with the patients. They might not be with them long, but there are no other distractions and they have a chance to bond and show interest in that patient,” explains Judy Bee, founder of consulting firm Practice Performance Group in La Jolla, Calif. Contrast that with the front desk that has waves of people approaching them while the phones are ringing and medical assistants are coming up and asking for records. “If your job all day long is greeting people in that frantic environment, where you get no positive feedback and really you’re the sacrificial lamb when doctors are running late, you have a very huge potential to be too busy to be nice.”

The division of job responsibilities, of course, also makes it easy to pass the blame, notes Sodikoff. “In-fighting and bickering happen in any organizational group where one side can blame the other if things go wrong,” he says. In a doctor’s office, he says, “it’s too easy to pass the blame when the patient complains.”

Scheduling

Often, angst among the ranks centers on scheduling. “You have front-desk clerks, who are not medically trained, responsible for booking patients,” says Lavallette. “You ask them to make that judgment and then you get medical assistants feeling put upon because the scheduling clerks tried to squeeze in another patient or because they put a patient who really needs 20 or 30 minutes into a 10-minute slot.”

A good solution? Let you, the doctor, decide how much time patients will need. Rather than allocating 15 minutes for every patient, for example, indicate on the patient encounter form at the end of each visit not only the diagnosis and procedure codes you used, but how much time that patient will need for her next appointment. “That creates a more realistic schedule,” says Lavallette. “It allows everyone to be more on time so it gets rid of that friction.”

For new patients or new episodes of illness, you should decide in advance how much time your front-desk clerks should allot - usually between 15 and 30 minutes, recommends Lavallette.

Create teams

Another good way to mend fences and improve work flow, says Lavallette, is to decentralize your office. Assign each physician one front-desk clerk and one medical assistant or nurse who work together at the same desk. Larger offices may even choose to assign a third staff member per doctor, a “greeter” who registers patients, handles referrals, and checks patients in and out. During the busiest parts of the day, says Lavallette, when the office first opens in the morning and when it reopens after lunch, the greeters can be used to help answer phones and pinch-hit on the front desk.

“Put the scheduler at the same desk area as the nurses so when there’s a phone call they can make a decision instantly about how much time that patient will need, or get a prescription written quickly,” he says. “The really effective offices are using this decentralized system more and more, which positively affects quality of care.”

Such an approach, of course, also helps the front-desk clerks develop relationships of their own with the patients, a luxury once reserved for clinical staff. “Eventually, they get to know that patient a little better so they know where to slot them in the schedule, which is where most of the time gets lost each day,” says Lavallette.

Collaborate

Where possible, it can also be instructive to put team leaders from both departments together to create better working solutions. For example, create a task force to develop a message-form template with basic questions. “You have a front-desk clerk who takes a message for the nurse based upon what the patient is telling her and the back office looks at the message and says, ‘What the heck does this mean?’” explains Bee. “Now frustrated, a busy MA or nurse walks up to the front-desk clerk and says ‘I can’t tell what I’m supposed to call her about.’”

The genesis of the problem, of course, is that the front-desk clerks have no idea which questions are pertinent and don’t have time to write “Gone with the Wind.” By collaborating, your staff can create a brief form with appropriate questions and prompts that tell the nurses everything they need to know. “You’ll get faster and better messages and the collateral benefit is that you get front- and back-office staff working together to find solutions to a problem for both sides and conflict is reduced,” says Bee.

Automate

Indeed, whatever you can do to streamline operations not only improves the patient experience, but helps create happier employees. For Michael Jones, practice administrator for Women’s Health Advantage in Ft. Wayne, Ind., an 18-physician OB/GYN practice that sees 700 patients a day, that meant implementing an electronic health record last year. “We had huge friction between the clerical and clinical staff, especially at 9 a.m. and 1 p.m. in the afternoon, because of the lines that formed in our waiting room,” recalls Jones. “The patients were not getting into the exam rooms fast enough.”

The software they implemented from Greenway Medical Technologies enables patients to use a secure online portal to self-register, make appointments, leave their health history online, and leave messages for the staff. “Today, operations at the front desk are so much more smooth,” says Jones. “We get up to 600 patient calls a day about medication or requests for records and already 20 percent of those are asking their questions online. We can usually get back to them within 20 minutes.”

With the time the automated system freed up, says Jones, the practice is now able to conduct weekly meetings with everyone on staff to discuss ways to further enhance the patient experience. “Now we’re all using the same product so we’re all on exactly the same page,” he says.

Create teamwork

Smart move, says Lavallette, noting office meetings are key to breaking down the walls that separate your staff. Weekly (or at least monthly) meetings give your employees a chance to interact, voice frustrations, suggest process improvements, and head off small problems before they become large. “Physicians should be taking the lead and finding out what’s going well and what’s not,” says Lavallette. “Getting everyone together helps develop that relationship between the front- and back-office staff.”

Another recommendation is to cross-train your staff so medical assistants understand what the front desk endures and vice versa. “When a doctor is on vacation and the back-office staff have a little extra time, put them up at the front desk for a few days,” says Bee. “They might be better at scheduling and at the phones because of their experience with patients, but they will not understand how patients are manipulative and pushy and try to get what they want out of front-desk people.”

Conversely, when new front-desk clerks are being trained, have them spend a day shadowing the back office staff. “That gives them an appreciation for how much it screws up everyone’s day when you schedule two patients back to back that require equipment they need to break down and sterilize,” Bee says. “Walking a mile in one another’s moccasins is not a bad idea.”

Fix the job

It’s important, too, to remember that front-desk clerks have a demanding and thankless job. Making matters worse, their job is among the lowest paying positions in the healthcare field, which breeds more resentment.

“It’s not uncommon that the front desk is asked to put in all the patient demographics from registration forms and that’s hard to do when you’re being interrupted constantly,” says Bee. “If you mistype a single digit in the patient’s Social Security Number, that’s going to screw up billing. Unfortunately it won’t be obvious to the person making the errors and now you’ve got office conflict because ‘those idiots at the front desk obviously don’t know what they’re doing.’”

The answer, she says, is to improve the job. That’s done by either organizing responsibilities so there’s ownership and accountability for each office function (scheduling, billing, phones, patient registration), or hiring another person to help meet demand. Indeed, even the most efficient workers won’t be able to keep pace if you’re understaffed.

A solo practice usually can skate by with a single front-desk clerk who wears all hats, but larger groups should have at least one clerk for every two phone lines - particularly if that person is also being asked to schedule appointments, says Bee. They also should have one or more employees (depending on the size of the practice) designated to greet patients and check them in and out.

At the same time, it’s a good idea to touch base with your local association or colleagues at networking events to ensure your salaries are competitive - or better yet, on the high end of the pay scale. That not only ups the caliber of applicants, but also helps reduce costly turnover. “If you offer rock bottom wages, guess who applies?” asks Bee. “Rookies. Consider your front-desk clerks to be part of your marketing team. Any callers who contact your office talk to these people first. Every patient has to meet them. This is not an entry-level job.”

Be the boss

Finally, Sodikoff says your management staff must be skilled at conflict resolution. “You need a very solid office manager who knows how to nip arguments in the bud and address it - to call those people into a meeting and get it resolved,” he says. “Most of all, they need to keep reminding people that they work on the same team.” In cases where bickering is pervasive (it’s not just one or two people you can dismiss), you may need to consider hiring a human resources consultant who specializes in team building.

Doctors, meanwhile, can do their part by clearly communicating the practice’s mission and ensuring everyone on staff buys in. “Take a look at your office,” says Sodikoff. “Is the whole office functioning as a team? Do they truly understand the mission and core values of the office? You’re the boss. Tell them what you value and make sure you believe it.” Employee satisfaction often climbs considerably when everyone realizes they’re chasing the same goal.

At the end of the day, most employees really want to work in a professional setting. “There is nothing more motivating or energizing than working as a member of a highly functional team - I don’t care where you are,” says Sodikoff. “You can end most of the bickering and gossiping if you develop an extraordinary office where everyone works together.”

Shelly K. Schwartz a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for 12 years. Her work has appeared on CNN-Money.com, Bankrate.com and Healthy Family magazine. She can be reached via editor@physicianspractice.com.

This article originally appeared in the November 2008 issue of Physicians Practice.