Stephanie Stephens

C. Nicole Swiner, MD, has worked hard to create a better work-life balance for herself. She transitioned from a hospital-owned clinic to private practice eight years ago and now is one of two physicians at Durham Family Medicine in Durham, N.C. She knows that devising best practices and strategies before they’re needed can go a long way toward keeping the “flow” in “workflow.” 

Here’s how to strengthen organizational workflow within a practice to make sure everything isn’t always the physician’s responsibility-a surefire set-up for burnout.

The best thing she’s done to improve her sanity is to hire someone who functions like a scribe, says Swiner. “I should have done it sooner. Now I focus less on note-taking and finishing and more on being able to listen to my patients instead of staring at the computer.”

She knows time is money. “Now it takes me 15 minutes to do 15 to 20 notes,” she says. “Paying a premed or grad student to scribe gives me time to see two to three extra patients in a day. They gain knowledge by working with me, and we both win.”

Ideally, everyone works to maximal capabilities and training, says Swiner, who also works with her LPNs and medical assistants so they understand her organizational structure and can support her at “full capacity,” meaning they can rise to the ever-changing list of tasks that occur in the practice every day.”The fewer phone calls and less paperwork I have, the better my life is,” she says.

Leading contributors to the pervasive problem include increasing administrative and documentation burdens, and the pressure to do more with fewer resources, says Nisha Mehta, MD, a radiologist based in Charlotte, N.C., who writes and speaks about physician burnout.

“To address this, practices need to take a sincere look at workflow, identify areas where other members of the healthcare team or staff can help, and then devote resources and training to make this possible,” Mehta says.

“The first thing physicians sometimes need to understand is how to ask for help,” says Kenneth T. Hertz, FACMPE, principal consultant for the Medical Group Management Association Health Care Consulting Group. “Remember, too, that there isn’t always one solution, i.e., ‘If you do this, everything will be fine.’”

Enter the practice manager, who can help build teams “to pull people together to solve problems,” says Hertz. “This requires collaborative effort, knowing you can’t solve everything by yourself. Practice managers really can help when we’re able to analyze things from the outside, without being in the middle of them.”

Make work performance expectations very clear, up front, Hertz says. “For example, say to your trusted nurse, ‘When I come into the exam room, please have this and this laid out for me. And check the chart to make sure lab and X-ray results are back.’”

In addition to the nurse, the receptionist is just one staff member who may see patients before the physician and should process them quickly, says Hertz. Checking them in and obtaining their medical files, confirming current insurance, address, phone, and emergency contact efficiently prepares them for the next steps.

“Then [the patient is] ready to be seen so the doctor can walk into the exam room and do his or her job. Everyone needs to accept responsibility for their little piece and to know that everyone succeeds or fails as a team,” he says.

Remember to recognize good work, says Hertz. “You can do this when you praise your staff. It’s especially powerful from the doctor, who might say, ‘Thank you, it was a great day today.’ The employee on the receiving end walks on air for the next two weeks and now wants to continue to rise to the occasion on the job.”

Be patient with staff, since sometimes, practices can be quick to let valued staff members go for reasons that aren’t so well thought out, says Mehta. She suggests that maybe it’s ultimately beneficial not to focus on the “small stuff,” but to appreciate the broader contributions a seasoned staff member makes to the practice workflow.

“Focus on the retention and satisfaction of valuable, well-trained staff so that you’re not wasting time, money, and effort on recruitment and training of new members,” Mehta says. Think about creating efficiency in the practice-then preserving it.”

Acknowledge that just as the physician has a life away from work, so do staff members, says Hertz. Try to be empathetic and flexible when the biller, who may also have a husband and two children, reports that one child is really sick and asks for time-off consideration.

Workflow is also better without problematic patients, so don’t hesitate to make necessary changes, says Swiner.
“Taking that action is appropriate when patients are late, cancelling or no-showing, not taking medications correctly, or being belligerent with staff. You have every right to ask them to find someone who suits them better,” she says.
This tactic can result in immediate benefits, says Swiner, for both doctor and patient.

“I’m much less stressed when I look at the schedule and don’t see as many patients that give me heartburn. And it may be healthier for both of you,” she says.

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Learn to delegate responsibly to help ease pressure on physicians.

Manage practice workflow to reduce burnout

When she was younger, primary care physician Dana Corriel, MD, worked at Disneyland as an outdoor vendor in a bright yellow uniform. There, says the director of quality at Highland Medical, PC, in Pearl River, N.Y., she and her fellow employees of the park felt like family.

That feeling, she says, results in employees being happier and at a medical practice, patients pick up on that.

To achieve this balance, employees’ requests need to be respected-as do the employer’s.

A former practice owner, Corriel operated on the family principle. Employees were given the benefit of the doubt and requests for sick time were typically honored. If “abuse” occurred, she’d discuss it with the employee, but always aimed for a mutual respect and understanding from both sides.

Now in her hospital-owned office, employees who can’t find child care can bring sick children in to play in an isolated room, instead of not coming to work.

“[Doctors] feel we can’t call out or we’ll feel guilty,” she says. “There was a stigma attached to that, even during the rigorous years of residency training.”

Some practices in the hospital’s system have adopted strict rules now, even docking employees their vacation time when offices close for a snow day. “That doesn’t seem fair,” she says, “but those are the hospital’s rules. It makes us think long and hard before closing the office.”
To allow some flexibility to staff while also maintaining a business, plan to get creative and organized about it all, says Kate Othus, MHA, of Aldrich CPAs and Advisors in Oregon. She recommends these seven strategies:





The idea is to pool vacation days, sick time, and an employee’s personal time, so the employee can use what they need when they need it. Think about work-life balance. According to the Society for Human Resource Management, PTO excludes paid holidays, such as Labor Day, Memorial Day, and Thanksgiving.

“PTO allows the employee to say, ‘I need the day off,’ without explaining why, so it creates some privacy for them,” says Othus. Salary.com notes that many healthcare organizations provide one set amount of paid days off for use at the employee’s discretion. Days off generally accumulate through years of service and the level of the employee within the organization.



An employee handbook allows policy to be set in stone and avoid future conflict. “Maybe you think you’re creating a more flexible work environment,” says Othus. “But if you go case by case, instead of following what’s documented, and a couple of employees compare notes, you may have to deal with poor morale issues, or be accused of favoritism-and not by design.”



Othus recommends a tracking system as part of your payroll software, to chronicle absenteeism. “Then you have actual data to measure, if an employee’s requests or time off become a problem,” she says.

Creating a record also means that when Employee A asks, and there is a record that they’ve been prompt and diligent, you can say, “You’re always here, and you can absolutely take the day off or leave early if you need to, because you always more than make up for that time.”

Conversely, if Employee B is almost always late, and may be having other “social” issues at work, and both are impacting their ability to perform to expectations, documentation is key when you say: “Wow, you were late five times out of 20 last month, so I’m going to have a hard time granting this request while your work piles up, and your co-worker is being asked to cover.”

That trumps a more subjective response such as, “Well, you’ve ‘kind of’ been late a lot,” and now you’re into the “feeling” part of deciding time off when you need to be tougher. Make sure from the get-go that policies are written, updated, and understood, Othus says.





Maybe you’re wondering, “Is this vacation time or PTO?” Federal and state guidelines come into play, and since you’re a healthcare professional and not a lawyer, it’s always best to seek the advice of a practice employment attorney to ensure you’re not violating any statutes. Develop the policy, have it reviewed, and then explain it to your employees, maybe more than once.
 

With a PTO program, you’ll need to make a few decisions. For example, is the time earned based on accrual and if so, can employees take time prior to full accrual? Your practice will need to develop guidelines for maternity, paternity, adoption, and surrogacy leave, along with bereavement leave. And, don’t forget jury duty. Have your handbook reviewed by your employment attorney, because issues related to leave can be complicated.

Having a grasp, or paying someone to have that grasp, means less disruption to your small practice, says Othus. “Most small, independent practices run lean, with just the right amount of staff, or maybe even one short,” she says. “It’s rare to be overstaffed and physicians tend to err on the side of ‘just right.’”



It isn’t ideal when one employee has already gone to Mexico on a honeymoon, and another got called on to jury duty you thought would be one day, but could be long-term. “You may need to roll up your sleeves and call a temp service. And that person may not initially understand the organizational workflow, which is tough,” says Othus. “Still, it’s an option.”



Invest time into your human resources infrastructure so staff knows how to use their benefits. “This impacts your culture, which impacts patient care,” Othus says.

Physicians can be both firm and fair when employees need personal time away

How to manage staff time off

The hardest part of running a solo private practice for the past 15 years is being an employer, says OB/GYN Donna Ivery, MD, of Titusville, Fla. “I find it particularly stressful because the behavior and competence of your staff can make or break your practice,” she says.

Ivery says that during her career she has fired four employees, but has had more than 30 come and go. Some employees made it easy on her to let go: “I’ve had them sneak out the back door without saying a word-[not even a] ‘goodbye,’” she says.

No one said firing an employee-particularly a long-term staffer-is pleasant, says Andrew Halley, of Halley Consulting Group, LLC. It’s another one of those subjects that isn’t taught in medical school. However, completing the process while following state and federal laws ensures that a termination does not become a lawsuit that drains precious time and money from a practice. 

Compile an employee handbook that details practice policies and includes a termination  section. Consider it both great communication and great protection. Before it’s written, get input from an employment attorney. “An hour spent doing that, and then again for a review when you have finished it, can save you thousands of dollars later on,” Halley says.

Make sure each employee receives the handbook and understands it. Ask if they have any questions. Check out basics on handbooks from the National Federation of Independent Business (bit.ly/NFIB-handbook) or a primer from the Medical Group Management Association (bit.ly/MGMA-handbook).

“Lay  out employee expectations from the beginning,” says Ivery. “Then there’s no confusion. I was guilty of not doing this in the beginning and it cost me.” 

Ivery adds that if you think a new staff member may not be the right fit long-term, you are likely correct.

“People can’t fake being a good employee,” she says. “If a person is four to five weeks into their 90-day probationary period, and they’re not performing, don’t expect it to get better. Understand you have a problem on your hands and do something about it.”

Remember that an employee cannot file for unemployment benefits unless they have met the requirement for time worked or wages paid, Halley says. Each state has different rules, and as an employer practices are charged a tax to help pay for unemployment insurance (UI).

“Your UI tax rate depends on how many of your former employees qualify for benefits. Your probationary period for  new employees should be shorter than the minimum time worked requirement for your state if you want to minimize your UI tax,” Halley advises.

Following the theories of organizational psychologist Bradford Smart, Halley reminds practitioners what happens when they drag along “C”- and “D”-grade employees. 

“If you fail to terminate poor performers, you drive the ‘A’ and ‘B’ players away,” he  says. “They get frustrated, harbor resentments, and leave, because they can find jobs anywhere they want. They are hard to come by, but mediocre employees are a dime a dozen.”

If an employee starts slacking because “they have non-work obligations” that require more time and attention, that’s not the practice owner’s  problem, Halley says. “They had these obligations when you hired them, and it doesn’t matter if you knew that-they still signed on to do a job for you.”

“Ask them to leave their problems at home or in the parking lot,” says Ivery. “If their kids need to go to the dentist, I recommend they do that on an administrative day-when no patient appointments are scheduled-so as not to impact patient care.”

Ivery reminds employees that if she can’t see patients due to low staffing levels, then the practice won’t make money either-and that affects employee salaries.

Practices with fewer than 15 employees are exempt from some federal employment regulations, Halley says. “Make sure you understand the basic employment laws in your state. Your attorney will help you know if you are considered an ‘at-will’ employer.”

An at-will practice owner can fire  anyone for any reason in almost any state, and of course, the employee can quit, he says. Additional federal laws must be considered after 15 workers are hired; specifically, laws dealing with discrimination, harassment, and the Americans with Disabilities Act.

Another threshold occurs at the 20-employee level, where age discrimination laws start to apply, and another at 50 that adds the Family Medical Leave Act and Affordable Care Act, among others.

“I tell my clients that an employee should never be totally surprised they’re being terminated,” says Halley. “A good employer provides effective feedback to employees along the way, regardless of the number in the practice.”

This can be done with a performance improvement plan, so the employee fully understands what is expected of him or her, he says. “They should already know what the deficits are, and whether they are meeting the expectations that have been set for improvement when they’re brought in for a termination discussion.” 

Never fire an employee without a witness. “We have a litigious society, and an employer should also never broadcast-on social media or otherwise-why they terminate an employee,” Halley says. 

“Remember, anything you say can be used against you,” he adds. “However unfair it may seem, the former employee gets to say whatever they want, but we should never retaliate or air our complaints about the former employee.”

A witness to the termination will make notes about the exchange and remains a credible back-up in case the terminated employee sues.

Halley says that as a matter of ethics, he advises never terminating an employee over the phone if it can be avoided. 

“It’s just bad form. Besides you’re better off face-to-face so you can have that witness,” he says. 

No one likes to fire an employee, but if someone is dragging down the practice, it’s time to make a change

How to properly fire a practice employee

	Daniel Bluestein, MD, CMD, is a primary care physician and an expert on the revenue potential from the Medicare Annual Wellness Visit (AWV), added as a benefit of the Affordable Care Act in 2011. 

	Here’s what he says you should know to maximize this specific visit for your patient and for your practice.

1. It’s different from and better than a “regular” physical.

	The AWV is an opportunity to really coordinate care, he says. It’s a time to talk proactively about the “whole” patient, especially their medical and family history and current health conditions, along with medications and supplements. The provider can also obtain specific vitals, such as height, weight, body mass index, blood pressure and vision, and discuss recommended screenings and vaccinations.

	Bluestein says that AWV can be reimbursed over and above the standard office visit Current Procedural Terminology (CPT) codes, and has some other perks as well.

	“If necessary, providers can still add a significant, separately identifiable evaluation and management service code from the same physician on the same day of the procedure or other service if applicable,” Bluestein says. 

	The wellness visit is also a golden opportunity to discuss the extremely important topic of advanced care planning and for referrals to community-based health resources if applicable. The CPT code 99497 for the first 30 minutes of advanced care planning is $86 and for each additional half-hour is $75. 

	Also, value-based reimbursement programs include calls for documenting quality improvement and the conduct of practice improvement projects. The wellness visit is a vehicle for meeting those stipulations, Bluestein says.

3. It’s an investment in support success.

	Bluestein says internal polling at his office found that most patients had never heard of a AWV, but wanted one when they did. Historically, the uptake on patients taking advantage of AWVs is quite low. A 2014 CMS report shows that a mere 14.5% of eligible Part B fee-for-service beneficiaries took advantage of the service.

	“Patients have to have buy-in,” says Bluestein, “and they need to understand this visit isn’t a physical and this isn’t the time to come in about a sore knee.”

	Remind patients they can have an initial AWV in their first year of Part B eligibility, and then an ongoing, subsequent AWV starting in their second year of eligibility, Bluestein suggests. The visit itself is 100% covered by Medicare, though there may be other charges for immunizations, lab draws, etc.

	“It’s also a way to further engage patients and encourage their loyalty,” he says. “Patients generally like these visits. The strongest predictor of getting further wellness visits was having an initial one in the first place.”

4. It provides quality time with patients.

	This is the clinician’s chance to spend quality time, usually 40 minutes to 60 minutes, with a patient. The conversation may yield an open exchange of information, and the patient may disclose other problems that require follow-up care-for which the practice really can bill. Remember, too, that the initial visit and follow-ups can be accomplished by the physician, or by a physician assistant, nurse practitioner or other medical professional or team directly supervised by the physician. 

	“Remember that your interventions with the annual wellness visit may reduce the likelihood or reduce the duration of more serious problems later for a patient,” Bluestein says. 

What you should know to maximize this specific visit for your patient and for your practice

Author | Stephanie Stephens

Articles

Manage practice workflow to reduce burnout

How to manage staff time off

How to properly fire a practice employee

4 benefits of Medicare Annual Wellness Visits