Staff Management

Like so many aspects of your medical practice, personnel management and human resources (HR) are just a few activities that you surely didn't spend years in medical training to do -- and you may just be happier avoiding them altogether.

In fact, physicians are more inclined to lend a hand in almost any other area of their practices not directly related to patient care --  technology, finances, even selecting furniture for the waiting room --  than they are in human resources.

"A lot of physicians are frightened by human resources," says Robert Harvey, FACMPE, director of family practice clinics for Lawrence Memorial Hospital in Kansas. "They've heard the horror stories and see HR as one more complexity to practicing medicine, and it wasn't why they went to medical school."

While it may be scary to some, there's no avoiding the fact that it takes well-trained and motivated people to help you deliver top-notch medical care and process the mountains of paperwork required for reimbursement.

But if HR is the means to managing the resources --  your staff --  needed to support your revenue-producing activities, why do many physicians give it so little thought?

Isolation is one reason, says Harvey. Busy physicians who work mainly with one or two nurses or medical assistants become isolated from the needs of their other staff, he says.

"Clearly, physicians do not have time to become HR managers, but knowing something about the HR structure gives you a clue to what makes employees tick and how the practice works," he says. "If physicians understood [human resources] more, then it would help them understand how their practice works."

Fortunately, getting more involved doesn't mean jumping into day-to-day management, says David Holloway, MD, of Fort Wayne, Ind.

"Physicians should be more involved in the oversight of HR policies and setting employee performance expectations ... but should really avoid day-to-day intervention," he says.

Holloway describes his job as part medical director and part team leader for several dozen physicians. "A lot of what I do is trying to get physicians to understand that part of their practice leadership role is coming to a shared understanding that we are running a business," he says. Every responsible business owner should know the basics of employee management, he adds.

"Stay involved but don't micromanage," is the tack that Peter LoPresti, DO, and his colleagues at Harford Primary Care in Bel Air, Md., take. He and the other physicians at the practice's bustling Edgewood satellite clinic north of Baltimore rely on their office manager to handle the many details of human resources while keeping "a hand in the decisions to hire and fire," for instance.
With that said, Physicians Practice offers these suggestions for a "stay involved" approach for physicians whose responsibilities include --  however grudgingly they accept them --  management and oversight of employees.

Benchmarks lay the groundwork

Human resources isn't just touchy-feely theory, says Holloway. Nor is it all rules and regulations. Effective human resources policies reflect a practice's goals -- and are aligned with its current financial situation.

To get started, he suggests, locate current survey reports such as those published by the Medical Group Management Association (MGMA) that describe the median percent of net patient revenue that goes to staff salaries and benefits for your specialty, group size, or group ownership structure. The practice's board of directors or management team should target a staff expense percentage amount as a benchmark to achieve, but not exceed.

For primary-care practices, 25 percent to 35 percent of collections typically are spent on staff. Medical and surgical specialty practices usually spend the same amount of money, but as a percent of collections their spending ranges from 15 percent to 30 percent.

"Once you know the amount you will spend, but not exceed, on staffing, you can design the HR policies, pay practices, benefit structures, and so on that will help you reach that goal," Holloway says. Working through the process with a benchmark in mind can help a medical practice decide if it will rely on overtime or try innovative staffing or scheduling strategies to handle fluctuations in patient demand for services.

Setting pay ranges for clinical and administrative staff positions is the next step. The ranges are typically based on what is paid for similar positions in the local market. Regional information is available from sources such as the Staff Salary Survey published annually by The Health Care Group consulting firm (www.healthcaregroup.com). You can also get an idea of what various positions earn from the U.S. Bureau of Labor Statistics (www.bls.gov) as well as from your state medical society, national organizations for the various professions working in your office, and from local hospitals.

Another simple and easy way to judge the local market is to check the local newspaper's classified advertisements for healthcare jobs.
There are several ways to turn a staff expense benchmark into HR policy, according to Holloway. Some groups develop a staffing matrix. "For example, they say that for each physician at such and such volume of patients or procedures we'll have 0.8 front-office people, 1.2 nurses, so many billing staff, and so on," he says.
"As you develop the spreadsheet of this staffing matrix, you establish an overall group philosophy to operations management," Holloway says. "What you consider a best practice governs not only how you manage staff but more importantly how you will manage workflow."

For example, a goal to provide each physician with two clinical support staff instead of three may require a practice to rethink how it deploys other staff in tasks such as rooming patients, taking medical histories, and the other tasks related to the patient's visit.

Physicians at risk

It's no wonder that physicians feel some trepidation when it comes to human resources. Medicare, Stark II, HIPAA, and other regulations and statutes already add enough complexities to practicing medicine. Why take on any more?

"The physician owner is the one who's going to be liable if harassment or discrimination occur, so they and their staff need to be educated on these issues," says Jennifer Moore, an Atlanta-based attorney specializing in labor and employment law for the international law firm Jones Day.

"Medical practices have been pretty cavalier about HR," says Joyce Lynagh, practice manager at Harford Primary Care. "There's always an attempt to make everyone comfortable." Lynagh, who manages a staff of more than 130 scattered at the multispecialty practice's several sites, says that until recently many physicians didn't realize the risks of not taking a professional approach to managing personnel, but "... they do have that ultimate liability."

Even though you don't need to know the intricacies of discrimination and harassment laws, you should know the basics. Lack of knowledge in this area is not only risky, but potentially expensive.

Perceptions of discrimination based on age, sex, or race can occur before an employee is even hired. During the hiring process, Joan Roediger, an attorney with the Philadelphia law firm Obermayer Rebmann Maxwell & Hippel LLP, says to beware of the many off-the-shelf job application forms still available that contain now-illegal requests for information about applicants' marital status, religion, physical impairments, etc.

When it comes time to interview job applicants, keep in mind that it's no time to get chatty. That's how inappropriate questions like, "Are you planning on having more kids?" or even, "How old are your children?" can get asked, says Roediger. An unsuccessful applicant might conclude that she failed to get the job because you won't hire women who have small children.

"You want to be friendly, you get to chatting, and the next thing you know you've got them talking about their kids," she says. "I don't care if the applicant is nine months pregnant at the interview, don't ask!"

What you should ask are questions that relate directly to the job, such as, "This position's hours are from 7 a.m. to 3:30 p.m.; can you work those hours?"

According to Nicholas Giampetro, an attorney who advises several medical practices in Maryland and surrounding states, the safest way to conduct an interview is to avoid all discussion of personal matters, even if applicants volunteer information.

"If someone opens the door to a line of questioning in a job interview, my advice is don't pursue it," he says. "Keep focused on whether this person can perform the essential functions of the position."

It's OK to ask if an applicant speaks a foreign language -- or even to require it for a certain position. Many practices want to serve non nglish-speaking patients. However, it is illegal to ask an applicant's nationality, for example.

Handle complaints with care

Once employees are on board, harassment accusations can still be troublesome for employers -- and the attorneys who defend them. The stakes are especially high for physicians. In addition to punitive damages, a harassment judgment against a physician could bring state licensing sanctions. Accusations of unwanted touching also can open the door to criminal sexual battery charges, notes attorney Giampetro.

"In a closed environment such as a small medical practice or an operating room, there is that constant pressure and familiarity with your staff that can breed some of these problems," he says.

Fumbling complaints about harassing or discriminatory behavior is a common risk, Moore says. It happens when the physician ignores the line between "employer" and "friend" in dealing with staff.
Moore says the problem often starts when an employee informally reports discrimination or harassment to a manager or a physician. "They'll say something like, 'I don't want to get anybody in trouble or file a complaint but you should know about this,'" Moore says. A plaintiff's attorney could later argue that the physician or manager who tried to quietly solve a problem was actually covering it up.

Moore and others suggest documenting all harassment and discrimination complaints -- formal or informal. Note the problem, the name of the person making the complaint, what was investigated, who investigated it, what conclusions were reached, and what was done to resolve the issue.

"Just because the employee doesn't pursue it through official channels doesn't mean you are relieved of your responsibility to respond, investigate, and put a stop to the discrimination or harassment if it's going on," she says.

Many times discrimination complaints turn out to be merely personality clashes or disagreements with performance evaluations. But without documentation, the practice has little with which to defend itself later on, Moore explains.

Although very small practices may be exempted from federal labor laws that assess civil penalties for sexual harassment or various types of discrimination, several states and local governments expand the scope of the federal acts to include smaller employers, Giampetro says.

Besides, says Moore, your practice could grow to become covered by the federal laws anyway, and following the spirit of the laws is good for staff productivity, recruitment, and retention.

Put it in the manual

You may have never read your practice's human resources policy manual, but you should know what's in it. This manual, if done properly, should protect your rights as an employer -- but if it's written poorly, it can give those rights away.

Consider the manual as a general description of the practice's rules of the road. "[It] tells employees what's expected of them, the rules of behavior we expect from you, this is how our practice operates, and these are our policies," Roediger says.

There is no one-size-fits-all manual, she warns. "A personnel manual should be very customized to your particular practice and how your practice really works. A manual is only as good as your willingness to live up to the terms that are in it."

Roediger also suggests that personnel manuals contain explicit statements that:

• the manual is not a contract of employment,
• the employer has the right to unilaterally change policies at any time,
• employees work at the employer's will and can be dismissed at any time, and
• violation of the policies will subject employees to discipline, including termination from employment.

But be careful not to go into too much detail in the manual; otherwise it will be in a constant state of revision. "If you are in an employment-at-will state, as most are, then you should definitely have the flexibility to hire and fire employees as you see fit," she says.

For example, don't include a detailed description of the practice's disciplinary policies, especially if it includes a process of several steps known as "progressive discipline."

Progressive discipline can enforce fairness in larger practices but it can be a disaster in small groups where just one underperforming employee can cripple business performance, says Bob Vidal, a medical practice consultant in Denver.

"A detailed progressive disciplinary process in the manual might give somebody the idea that they are entitled to a due process before they can be terminated," Vidal says.

Progressive discipline works well for enforcing attendance and certain other policies. "There are some things that you should be able to fire someone for right on the spot, like drug use, stealing, or noncompliance -- but don't try to list them all in the manual," he says.

Moore recommends that employee manuals contain policies on:

• prevention of unlawful harassment,
• the practice's commitment to equal employment opportunities, and
• opposition to discrimination.

Manuals should also provide a broad description of the practice's vacation and other leave policies, and should state the need to comply with the practice's clinical policies as well as applicable federal or state rules and other regulations.

Make sure employees sign statements that they've read the manual and its updates, "so you can avoid the 'I never saw that' issues about your policies," Roediger says.

An alternative to a written personnel manual is to issue policy statements on major issues and ask employees to sign each statement after reading it.

"The most important thing about a personnel manual is not to put anything into it that you cannot live up to," Roediger says. "Don't put a sexual harassment policy in your manual if you or someone in your practice just can't refrain from off-color humor."

The physician's role

Keeping tabs on the entire spectrum of human resources is probably much more effort than most physicians are willing or able to put forth. So is there really a middle ground between micromanaging and neglecting the human resources business function?

Yes, say Harvey and others. Harvey suggests that a physician always remind his or her staff that they, too, are part of the patient care process. "What motivates [staff] is knowing that what they do is important to patients, which is why the physician needs to know what everyone in the practice does, not just his nurse or medical assistant."

But don't mistake good morale for motivation, cautions Harvey. "You can have a very happy staff that's happy doing nothing."
Human resources is more than just making everyone feel good, Holloway adds. He suggests that physicians advise and support administrators in developing major human resources policies and salary and benefits structures for nonphysician staff.

When it comes to day-to-day issues, the best role of the physician is to show respect, he says. "Create a respectful environment and treat everyone like teammates." 

And since physicians who own practices have both the ultimate authority and ultimate risk for what might go wrong in the practice, they should understand what's in their group's employee handbook and support those policies in word and deed, says Susan Kizirian, director of Southeastern Urological Center in Tallahassee, Fla.

"[Physicians] need to be sure that they annually review their personnel policies and approve additions, deletions, and amendments at their periodic governing body meetings, and require that their administrator enforce those policies," says Kizirian.

Finally, knowing what you don't know also is important.
"More knowledge is always better, but physicians at least need to agree that when an issue comes up, they will refer it to the administrative director and not get into areas they don't know about," Holloway says.

Adds LoPresti, "I rely on the office manager to make final recommendations. The manager is much more hands-on, but it's important that doctors are involved [in big decisions] because one bad or good employee can make or break your day."

Robert Redling, editor of practice management for Physicians Practice, can be reached at rredling@physicianspractice.com.

This article originally appeared in the March 2004 issue of Physicians Practice.