PRACTICE POINTERS

How to find and keep top-notch clinical staff

Skilled nurses and medical assistants make for satisfied patients—and a smoother-running, more lucrative practice.

By Gail Garfinkel Weiss
Senior Editor

Whether you're a solo practitioner or a member of a large group, you probably don't escort patients into the exam room and do the preliminaries. Your nurse or medical assistant takes care of that—and thereby sets the tone for the visit and helps define the practice. So you want to hire the best clinical staffers possible, because patient satisfaction depends on it.

And once your ideal clinical staffers are in the fold, keeping them there is well worth the effort. Here's what you need to do.

RN, LPN, MA: What's the best mix?

"Licensed practical nurses and certified medical assistants do pretty much the same thing in our office," says Becky Boyer, office manager of United Medical Associates, a 150-doctor multispecialty group in Johnson City, NY. "They assist with Paps and flexible sigmoids, give injections, and do phlebotomies and ECGs. The chief difference between them is the pay."

Although the pay discrepancy isn't dramatic—according to RN magazine's 2001 salary survey, office-based LPNs earn an average of $13.35 an hour, while MAs earn $12.80—it adds up over time, especially in a large practice.

Office-based registered nurses, on the other hand, command $17.50 an hour, the RN survey indicates. That's quite a bit less than the $23.55 an hour that full-time hospital nurses earn, making it difficult to recruit RNs even if you want to take on the additional expense.

So—except in offices where staff assists in procedures or tests that require RN licensure—practices are increasingly contenting themselves with LPNs and MAs or, more often than not, with MAs alone.

The four-doctor Lawndale Internal Medicine in Philadelphia is a perfect example. They have 11 medical assistants and no nurses, in part because "it's hard to compete with hospital salaries," says the practice's office manager, Helena Dahan.

But some RNs will accept less pay to escape the pressures of hospital work. And if you're a family doctor who wants a nurse on staff—to try to provide a higher level of service, or because you prefer to work in tandem with an RN or LPN—recruiting one might be easier than you think.

"The best thing about office nursing is the hours," says Sharon Bearor, immediate past president of the American Association of Office Nurses. "Although we might work 10-hour days, they're solid, steady, basic hours; we don't work nights or weekends, and we have holidays off. Hospital schedules aren't easily manipulated, nor are they predictable."

Bearor, who is nursing manager of Coastal Women's Healthcare, a Scarborough, ME, ob/gyn office with 27 nurses, also points out that "office nurses get to work collaboratively with a physician, and get to know patients better than hospital nurses do."

Recruitment: Go where the prospects are

Just as experienced investors use a variety of techniques to maximize profits, you're better off using several recruitment methods to attract clinical staffers.

"There's always newspaper ads," says Kelly Dietrich, practice manager of Physicians of the North Shore, an 11-doctor practice in Skokie, IL. (For tips on crafting an effective ad, see below.) "If we put an ad in a major newspaper, like the Chicago Tribune, they'll post it on the Internet. We're also near a hospital, and I'm allowed to list job openings there. We've used a couple of medical-specific employment agencies in the area as well."

Helena Dahan uses Philadelphia-area technical schools and community colleges as resources. "The schools have placement programs," Dahan says. "In addition, MA students have externed at our practice, and it's not uncommon for us to offer jobs to talented ones."

But the premier recruitment method, according to Dietrich, Dahan, and other office managers, is word of mouth. "I go by referral only," says Susan Genrich, the office manager of Selden Medical, a solo family practice in Selden, NY. "I created a network of office managers, and we use each other for staffing purposes. And I ask my nurses if they know anyone who's job hunting."

Sharon Bearor looks for possible recruits at job fairs and health fairs. "Whenever I meet nurses and nursing students, I ask them what they're doing. If they're looking for something different, I take their names and resumes."

The interview: What to ask, what to look for

"When I first call nurses and medical assistants for an interview, I want to hear if their phone voice is pleasant, because they'll be talking to patients. And I ask if they've had experience in an internal medicine office," says Mary Jo Marlowe, office manager for a six-physician internal medicine practice in Rochester, NY.

If the applicant shows promise, Marlowe arranges a face-to-face interview. "I want to see if she'll fit in, not only with the physician but with the rest of the staff," Marlowe notes.

Asking applicants what they're looking for before telling them about the job may forewarn you about potential bad matches, says Christine Hipple, vice president of training and organizational development with the human resources firm Total Compensation Services in Baltimore. "For example if someone is coming from a very hectic job and wants a change of pace—and you've got the craziest office in town, chances are, she won't be happy with you." Hipple also advises asking prospects what their best and worst bosses were like, in case their worst boss was similar to the person they'd be reporting to in your practice.

Hipple also recommends asking applicants how they spent their time on their last job, to gauge if their skills jibe with the requirements of the position. "I also ask what they enjoyed most about their last job, what problems they feel they solved extremely well, and what their approach is for dealing with difficult patients," she says.

Avoid Yes or No questions, Hipple counsels. Rather, ask for specifics that demonstrate experience and skill. Let's say your practice is very fast-paced. Don't ask, "Have you ever had a very busy job where you had to do a lot of things at the same time?" Instead, ask, "How many rooms have you kept going simultaneously? How did you manage it?" Or, "How do you triage large numbers of telephone calls?"

Helena Dahan asks questions designed to gauge interpersonal skills, such as "How would you resolve a conflict with a co-worker? What about a conflict with a patient? Suppose it was a violent situation? How would you keep a personal problem from interfering with your job?"

Physicians of the North Shore tests applicants' clinical skills. "If they're going to do phlebotomy, we have them draw patients' blood," Kelly Dietrich says. In evaluating nurses and MAs, Dietrich also checks front-office savvy by asking basic questions like, "What's the difference between an HMO and a PPO?" "Not all nurses are comfortable dealing with insurance companies," says Hipple, "but if they'll be expected to get treatment authorizations, they'll have to know who to call and how to deal with utilization departments."

Whether you're interviewing applicants alone or with an office manager, Hipple advises devoting 15 to 20 minutes to the interview and letting the applicant do 75 percent of the talking. "Because doctors are so busy," says Hipple, "they're tempted to briefly describe the job, then say, 'Do you think you can do it?' If the applicant says 'Yes,' they'll give her the job. You need to dig deep to find out if it's a good match."

Be sure to have a comprehensive job description handy, and present it to the applicant early on. It indicates what's expected, and serves as a starting point for the discussion that follows. Your hospital's human resources department might have job description templates that you can adapt to your needs. The Medical Group Management Association, too, has sample job descriptions in its Job Description Manual for Medical Practices, and the MGMA's Group Practice Personnel Policies Manual contains a sample job application form. For information on how to order, call 877-275-6462 or visit the organization's Web site, www.mgma.com.

A good candidate: Now what?

If all goes well, the applicant will want to know the salary and benefits you're offering, and you'll want names of and contact information for at least three references.

"We ask applicants what their salary requirements are," says Mary Jo Marlowe, "and we have a ballpark idea of what we're going to offer. But we might go up a bit if we feel it's going to be a good fit."

Salary is commonly based on community norms, but it's often tweaked to take skills, experience, and education into account. "Most state labor departments publish statistics for different job categories," says Keith Borglum, vice president of Professional Management and Marketing in Santa Rosa, CA. The Professional Association of Health Care Office Management does an annual salary survey; PAHCOM members can view the results on the association's Web site (www.pahcom.com). And some MGMA state chapters and county medical societies can provide salary data.

If job applicants aren't flocking to your practice, consider paying more than the going rate. Borglum explains: "If the pay scale ranges from x to y and a doctor is having trouble recruiting, I advise him to offer 20 percent beyond y. That amount seems to be meaningful; it's the difference between making $20,000 a year and $24,000."

Checking references is time-consuming and often frustrating, but it can yield valuable nuggets. To get the most cooperation from applicants and the people you'll call, Chris Hipple suggests that you get names and phone numbers of former supervisors before the job interview ends; have the applicant agree, in writing, that you can check references; and ask the applicant to tell the reference providers that it's okay to talk to you.

Your office: Make it a great place to work

To recruit office nurses and medical assistants, you have to offer them a competitive wage and decent benefits. To encourage them to stay, you must let them know—early and often—that they're a valued and respected part of your practice.

"Praise publicly and reprimand privately," says Keith Borglum. "And praise specifically. Instead of 'You always do such a good job,' say, 'You did an excellent job with Mrs. Smith. I know she's a problem.' " Another way to demonstrate that you value your staffers is to take their side against abusive patients. "Nurses and medical assistants often get bullied by patients," says Kelly Dietrich. "Having physicians back us up is so important."

Deborah Walker, an independent consultant with the MGMA Health Care Consulting Group, considers flexible schedules crucial. "That's an advantage medical offices have over hospitals in attracting and keeping nurses," she says.

At Mary Jo Marlowe's Rochester office, they "accommodate clinical staffers who need time off to attend to personal business." They also have two sets of nurses who job share. "That allows them more time for their families," Marlowe says, "and it helps the office because twice as many people can fill in if someone can't be here."

Marlowe also cites the need for autonomy. "Once nurses have been here long enough," she notes, "the doctors give them the authority to handle a lot of situations themselves. This gives them a greater interest in the practice."

Don't neglect the small stuff. Deborah Walker knows of practices where the physicians buy staffers lunch every day, and others in which staffers get spa memberships. "I think spontaneous bonuses are wonderful," Sharon Bearor says. "Something like a gift certificate to the mall, or a $100 check."

Helena Dahan attributes Lawndale Internal Medicine's high retention rate to cross-training. "With the exception of the receptionist, whatever one of our staffers can do, they all can do," she says. "They do desk duty and sign-in-window duty, work with the physician in various clinical capacities, and do phone triage. That way, they don't get burned out or lose any skills."

Giving staff the time and resources to acquire new skills is another important retention approach. A large group might have a training and development department, and invite speakers to talk to staffers about confidentiality rules, coding, and OSHA regulations. Smaller practices can offer time off for continuing education, and even pay for it.

The bottom line, though, Susan Genrich attests, is that "people want to be treated nicely, and they want to be appreciated for a job well done. If you do that, you'll have whatever staff you want, and they'll stay as long as you want."

Evolution of a classified ad

An effective ad is enticing, vivid, and brief, but not so brief that it obscures the nature of the job. The more refined your ad, the better your chances of attracting qualified applicants. The following samples from Keith Borglum of Professional Management and Marketing in Santa Rosa, CA, show ads in three stages of development, from poor to best.

Gail Weiss. Practice Pointers: How to find and keep top-notch clinical staff.

Medical Economics

2002;5:36.