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A medical practice’s culture plays a key role in hiring support staff

Medical Economics JournalMedical Economics April 2024
Volume 100
Issue 05

A healthy practice culture is vital to attract and keep top talent to serve patients.

Hiring staff: ©Nadia L - stock.adobe.com

Hiring staff: ©Nadia L - stock.adobe.com

Physicians know well the serious problems in contemporary American health care. They include rampant burnout, declining reimbursement, rising inflation, an exodus of clinicians at all levels and projected shortages of new workers, just as aging baby boomers need more care. The same conditions making it difficult to be a health care worker are making it difficult for physicians to find, hire and keep health care workers.

Physicians may feel frustrated about problems in health care writ large, understandably so. But many of those are beyond the control of individual doctors. So, what can they control?

Physicians and experts in recruiting and management emphasized the importance of the hiring process and of practice culture — the combination of patient care and customer service, workflow, attitude, communication, shared goals and flexibility that doctors must lead. Hiring and culture intertwine because physicians, nurses, medical assistants and administrative support staff all contribute to practice culture, and a healthy practice culture is vital to attract and keep top talent to serve patients.

“The thing about health care is the mission is good. It all comes down to helping communities and people be healthier,” said Ron Holder, chief operating officer at the Medical Group Management Association (MGMA). “And people want to do that. But they’re not going to want to do it in a toxic environment. They want to do it where they feel appreciated on a daily basis.”

The hiring process

Independent physicians are well trained in medicine — hard-working go-getters unafraid of challenges, often with an entrepreneurial bent. The right support staff members are vital for success but hiring them can be daunting.

“It’s scary, honestly, one of the most difficult things I’ve ever done,” said Matthew Grierson, M.D., who in 2023 opened his own physical medicine and rehabilitation practice in Seattle. As a former chief resident, he was used to leading the team.

“But this is a much different approach and when these are your employees, they count on you. Their livelihood is directly related to your success,” Grierson said. “And vice versa — your livelihood is directly related to selecting the right people.” He and his partner physician ended up hiring two full-time medical assistants and a part-time office worker.

Getting started

When a worker leaves a doctor’s office, staff members scramble to cover the duties and find a new colleague, said Kevin de Regnier, D.O., FACOFP, who operated for 36 years as an independent family physician in Winterset, Iowa. But preparing to fill an opening should be a chance to pause and reflect, he added.

“Job openings are kind of a pain for the business,” de Regnier said. “It’s also an opportunity, I think, to look at the position itself and say, is the way we’ve defined the position, the job duties, really working? Or is it something we could refine, and now that we’re going to hire somebody new, maybe get somebody with a slightly different skill set than the person who just left? So I think that preparation work up front is really important.”

It can be an opportunity to assess the practice culture and develop it by engaging employees and acknowledging their input, said Terry K. Bennett, M.S.N., RN, CHCR, president of the National Association for Health Care Recruitment and a former director of nurse recruitment at the Johns Hopkins Health System.

“If you really want to know what people like about the practice, I would sit down and talk to some of the top performers and ask them,” Bennett said. “I would say: What is it that you like about working here? And what should I be telling any potential candidates are the reasons they should want to come here?”

Determine salary

Pay is complicated because it may be difficult to pin down a competitive pay scale for a new position. Current staff members may see open positions advertised with larger salaries than they earn, and they can talk about the issue, said Guy Jones, M.D. In mid-2021, he opened an oncology practice in Reno, Nevada, growing it with another physician and a dozen staff, with plans to hire six more this year.

“You just want to make sure that you’re getting fairly compensated,” Jones said. “It’s got to be somewhere fair and commensurate to what you bring to the table.”

Professional associations for nurses and medical assistants compile salary data and may cite the U.S. Department of Labor’s Bureau of Labor Statistics, which covers numerous health care positions in its Occupational Outlook Handbook. Online job boards ZipRecruiter and Indeed aggregate salary data.

Third-party organizations such as MGMA and the American Medical Group Association (AMGA) tend to collect salary data because businesses do not like to reveal their exact costs to competitors, Bennett said. But physicians may informally ask peers about pay rates. Workers at any level may snoop online to look at competitors’ job openings and see what salary ranges are.

Staff referrals

If a position comes open, ask existing staff members whether they know anyone who could apply. “Employee referrals are the number one way to recruit and retain people. It does both,” Bennett said. When a new colleague is a friend or acquaintance of a current employee, that staffer wants to see them succeed, creating an incentive for the current worker to stay longer, she said.

Job descriptions and ads

Once you have ideas about the next ideal employee, draft the job description. If you are not much of a writer, be creative. When seeking two medical assistants and an office worker last year, Grierson borrowed job descriptions from a physician friend in another Pacific Northwest city. Artificial intelligence helped edit them.

It is important to create and refine those job descriptions to set expectations for the new person. They also can serve as a draft for a notice of opening.

Earlier in his career, de Regnier used local classified ads. “When you’re paying a newspaper by the word, you tend to be pretty cryptic in what you’re looking for,” he said.

Now, digital ads can be lengthy, outlining a broader, more in-depth description of the candidate and skill set you are looking for, de Regnier said. More specific ads will attract qualified applicants and weed out those sending out resumes everywhere.

Help wanted

There are numerous ways to spread the word about job openings, and physicians should consider them all. “You basically have to cast a bigger net than you’ve ever cast before, at this point,” Holder said.

Facebook and other social media sites, as well as online job sites such as LinkedIn, Indeed and ZipRecruiter are all fair game. A practice’s website or social media sites are possibilities. State and specialty medical associations may post openings; the same can be true of associations for medical assistants and nurses.

Local colleges and universities like to advertise that their graduates find success in the workplace. Many schools have online job boards and staff to match students with jobs, Holder said.

Bennett agreed. “If you can build a network with some of those community college school programs, you could have an ongoing funnel of potential candidates,” she said.

Jones and de Regnier said they had success finding staff by serving as a training site. One caveat: Education takes time, so it could slow your search if you need to wait three months until the next graduation, de Regnier said.

Not time for telehealth

Grierson, in Seattle, said that last year his ads drew at least 100 applications that he reviewed with his practice partner and others. In rural Iowa, de Regnier said his candidate pool usually was small, so his office manager typically would select the first round of top candidates.

Phone or video interviews are an option, but the physicians said face-to-face meetings are crucial. “Getting to look at somebody, watch body language and see how they interact is an important part of that process,” de Regnier said.

“You get a lot more information from somebody in person,” Grierson said. “And there are some people who just didn’t show up to the interview, and so that’s also good feedback to have. Or someone was 15 minutes late to their interview, and that’s also good feedback to have as you’re evaluating those skills as well.”

Tell me

In interviews, ask candidates about the great, the good and the not so good in their own workplace experiences. Listen for details, not theory.

“All the best interview questions start with, ‘Tell me,’ ” Holder said. “Tell me about a time that something — whatever it is you’re interviewing for — went really well. Then follow that up. Tell me about a time that you did something that didn’t go so well; what did you learn from that? Find out how they actually handle themselves in the situations that they’re going to be working in in your practice.”

Good candidates have good attitudes

Working in medicine requires training in technical skills and about the human body. It involves assisting patients dealing with ailments ranging from colds to cancer, and the accompanying pains, fears and frustrations. Figuring out costs and health insurance adds another layer of complexity.

Physicians need staff who treat people with patience, politeness and empathy, Bennett said. “Would you want to go to any hospital or doctor’s office and find grumpy people at the front desk? I certainly don’t want to,” Bennett said. Grierson agreed, emphasizing the soft skills that staff members need to work with patients dealing with pain.

“I’ve heard it a number of times: ‘Hire attitude, train skills,’” de Regnier said. “You can have somebody who’s got the best skill set but if they have a really [bad] attitude, they are not going to work out. If somebody’s bright and has a good work ethic and a good attitude, you’re going to get far more out of them, even if you spend some extra time training some skills for them.”


Not just about pay

Every worker wants a fair wage, but the current hiring environment is not just about pay. That is where the culture of an office comes into play.

“It is important for them mostly to have a good relationship with their leader, have a good relationship with their co-workers and feel like what they’re doing is important,” Bennett said. “If you can make people feel like that, you don’t have to pay them above market — you don’t even have to lead the market. You can be in a comfortable, competitive range and treat people well and they will stay with you.”

First-year turnover

Once that applicant-turned-interviewee becomes the newest employee, physician leaders must work to keep them. Recruiting a new worker takes time and effort, so the biggest expense to an organization is a new hire who leaves within the first year. It is a critically important metric for any practice and physicians and administrators must do all they can to minimize it, said Fred Horton, M.H.A., president of AMGA Consulting.

Mike Coppola, MBA, chief operating officer of AMGA Consulting, described working with an organization where thefirst-year
turnover rate had reached 40%. “That means out of every 10 people they hired, four left within the first year,” Coppola said. “So, all the energy and investment you made in recruiting that person, onboarding them, and then they leave. You have to start that cycle all over again.”

One strategy, according to Coppola: “Within a new employee’s first 30 days, there should be a conversation by that person’s leader saying, ‘Is there anything here that would lead you to leave the organization? Tell me now, and can we work through figuring out what a solution might be?’ You address that first-year turnover, you’re addressing culture, and you’re addressing the operational financial impacts. That’s critically important.”

Performance improvement plans

Jones cited the military ethic that if a person is not doing their job well, then the job of the leader is to make that person better. If a new employee is struggling with an element of the job, meet with them to lay out the expectations and solutions for improving.

Such performance improvement plans are not necessarily punitive or disciplinary actions. Rather, it is paramount to establish job expectations for support staff to benefit office workflow, morale and, ultimately, patient care, Jones said.

“We lay out the most important things. Number one is, patient care comes first, period. Without that piece we might as well not be here,” Jones said. “Then the second thing is good customer service, and that’s hard because we’re treating cancer, and it is hard to make people happy in that scenario.”

Re-recruit your staff

When it is time for evaluations, whether yearly or more frequently, do not just check the boxes if the worker is adequate or excellent. As you evaluate the staffer, re-recruit your staff to stay by asking their evaluation of the practice, Holder said.

“Make that a recruitment discussion: What are the things that are important to you? Why do you stay here? What do you want to see? What’s important to you?” he said.

Be creative

Employee appreciation may sound trite, but health care is a stressful profession. Experts agree that sometimes just saying thank you goes a long way, and not just with words. Grierson stocks a treat drawer with sweet and healthy snacks up to spicy ramen for days when lunch may not happen. His practice caters in part to athletes and dancers, including ballet dancers, so the staff attended opening night of “Swan Lake” to see how their work affected the lives of patients on stage.

De Regnier recalled one particularly difficult stretch of time, followed by a lull when he could arrange a visit from a local massage therapist for breaks and back rubs.

Compared with huge hospitals and health systems, independent practices often have more flexibility in scheduling and in circumstances. Communication can be easier. Those are real perks for staff and the physicians agreed that doctors’ offices should capitalize on them. Jones and de Regnier both recalled allowing staff to leave early occasionally for family, school or children’s sports events.

“We are not a big conglomerate with multiple layers of supervisors and bureaucracy,” Jones said. “If one of my workers needs something, they come to me. That’s it. I’m the manager. If they need something, they just ask me. And most of the time I’m going to say yes because I want to see them happy.”

Continuing education for employee retention

Career and professional development are becoming crucial for worker retention, said Sheena Singh, senior vice president ofconsulting firm Aon’s national health care practice. Depending on the practice’s size physicians may consider creating career tracks for workers.

“How do you give people the opportunity to stay within your organization and create more loyalty to your organization? That’s by supporting their development and opportunities to have a career path down the line. Not just a job but something that can become more of a path to continue to grow,” Singh said.

Part of a career path could involve promotion when workers train to develop new or existing skills. Traditionally, health systems have been better at creating clinical ladders for clinician advancement and to offer tuition reimbursement. Other employers are catching up in the market, Singh said, although Tonya Coram, director of health care practice for Kahuna Workforce Solutions, said hospitals and health systems remain far ahead of clinical practices in offering tuition assistance or reimbursement.

“Unless the clinic network is really ambitious and has really good professional development dollars, chances are there are some gaps with what they’re able to offer their staff to enhance their satisfaction,” Coram said. “I think they could really learn from the acute care side, but I think it has to do with money and what they’re able to do.”

Physician practices have tight cashflow, especially in primary care. They are not likely to cover hundreds of thousands of dollars for medical school, or pay for an unrelated liberal arts degree, Jones said. But recruiting and onboarding new staff also takes time and money. If a relevant certification or degree at a community college costs $10,000 or $20,000, physicians should consider investing in staff training for positions that are hard to recruit for, he added.

“That’s an important part of your growth, and in exchange you get their commitment for a longer period of time and then they get the win of not having to pay for their education,” Jones said. “If you’ve got somebody you know is working out, invest in them.”

Physicians may fear paying for an educational program will open the floodgates to requests from every worker expecting payment for every bit of new learning. That is not necessarily the case, Jones said.

Continuing education does not need to cost a lot of money. Within a practice, physicians can lead periodic seminars about their own areas of expertise, Bennett said. For example, discussing trends in patient diagnoses helps staffers understand what patients are going through, and could help with their own or their family’s health care while developing relationships that lead to employee retention.

“That’s sharing your own expertise and your own knowledge and a cup of coffee or a couple of cookies. It’s not an expensive endeavor,” Bennett said.

Continuing education does not necessarily have to be about medicine. Integrating new technology, such as phone or computer systems, or learning about stress relief techniques all could make great group learning sessions, Bennett said. She also used a seasonal example: Ask a local gardening shop to send a staff member to explain how to start seeds and pot plants in the spring.

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