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Chapter 1---PRIMARY HIRING CONSIDERATIONS

  1. How much staff do you need, and what kind?
  2. Job Descriptions
  3. Office Manager
  4. Compensation
  5. Where to find staff
  6. The Hiring Process

HOW MUCH STAFF DO YOU NEED? And what kind?
No magic formula exists for deciding how many staff people you should have, but there ARE some guidelines to help you make your decisions. Most decisions on number of staff are based on:

  1. Work needs
  2. Payroll cost constraints.

Because of the variety of services provided at a family practice office (or any primary care office), such practices spend approximately 15-20% of their gross on employee salaries.

MGMA surveys (according to MGMA Update, Dec. 1, 1997 edition, page 7) indicate an average 4-to-1 doctor-to-staff ratio, which would typically include:

  1. a nurse
  2. a billing clerk
  3. a receptionist/appointment/transcription person
    4.
  4. a person to assist both the front and back desk areas.

The starting point of 4-to-1 can be adjusted upward or downward to meet various practice needs.

How to tell if you possibly have TOO LITTLE STAFF:

  1. The office is chaotic every day, or at certain times of day.
  2. Earnings, visits, or referrals are falling off.
  3. You have a very fast-paced practice.
  4. You would like to delegate more tasks, but no one currently can handle the extra workload.
  5. You'd like to take on a larger patient load and spend less time on tasks someone else could as easily do.
  6. You have a very high caseload of HMO and/or PPO patients, all needing special paperwork.
  7. Your billing and collections are running far behind, and your staff "just can't keep up with it".
  8. You have a stressed-out staff or high turnover of dissatisfied employees.
  9. You would like to expand your range of services or practice hours.

Alternatives to Hiring More Staff

  1. Job Descriptions: Take a look at your current employees. Do they have job descriptions? Do they know what is expected of them? (Is no one doing a certain chore, or are three people overlapping on a chore?)
  2. Equipment and education: 
    1. Does your staff have the equipment they need to do work efficiently
    2. Are they up-to-date on insurance regulations and Medicare changes?
    3. If your collections are falling behind, take a look at what is currently being done by your staff. Is your staff able to devote enough time to this function, and do they do it efficiently, consistently, and regularly? 
    4. Could computers be used to a fuller extent in bookkeeping (using more or optional features of existing software)

For Brand-new Practices
New practices routinely start out with a small amount of staff and work upward. With NO patients to start out with, one full-time person who can handle both clinical and administrative duties. You should have someone in mind to become your second person, because this low-volume won't last for long. With only one assistant, you can probably handle a patient population of maybe three hundred patients without you or your assistant losing your minds.

When you have worked your way up to a staff of two, you would want to put one person in charge of the front desk area and one person in charge of your clinical area, but both should be cross-trained to an extent in order to assist one another. These people should be working full-time in order to provide continuity and consistency from day to day.

Subsequent Staff Additions
How your number of staff grows from this point depends on the nature of your practice and how it grows. You might want to consider adding part-time employees in increments.

Part-timers or Full-timers?
Full-time employees are necessary for a practice to provide continuity from day to day, but part-timers are also particularly useful for their flexibility in filling in a schedule, or for easing particularly chaotic times of the workday. If the backlog of work doesn't necessitate another full-time person, then a part-timer may be the solution. If you are considering adding evening hours, a part-timer would help fill this spot.

Another consideration regarding hiring part-timers is alleviation of paying overtime to existing full-timers. If your practice allows for a lower level of fringe benefits for part-timers than full-timers, then the addition of part-time staff may help relieve a short staff while avoiding more expensive benefit outlays. Some practices hire only part-timers to avoid paying of full benefits, but this type of arrangement may interfere with continuity of care for your patients. and part-timers traditionally have lower levels of commitment to a practice.

JOB DESCRIPTIONS---a useful management tool
 Specific job descriptions serve many purposes:

  1. Help you to hire the right people---people who are properly trained and interested in the duties they will be assuming
  2. Prevent overlap of duties and make sure all jobs are done---such as two people handling one aspect of insurance, but neither one is responsible. Or duties that aren't being done because NO ONE was told to do it. 
  3. Assign responsibilities---each person knows what they are responsible for, their authority in that area, and their accountability in that area. This also gives that person a chance to plan work, organize work, improve work, and take pride in their management and improvement.
  4. Evaluate performance---it's easier to assess a person's work if you know what they are supposed to be doing. Also allows you to give praise where praise is due, and lets you know WHO to talk to if some phase of operations is not going well.
  5. Give exact assignments -to temporary help or staff "filling in" for absences, vacations, etc. In this way, the work flow can continue, and current employees can appreciate what a multitude of work the absent co-worker does.
  6. Assign equitable amounts of work---so that each person can get his or her work done, and is not expected to carry out an unreasonable amount of duties.
  7. Reduce employee stress---person knows exactly what is expected of them.
  8. Efficiency---helps staff to prioritize work, increase performance, use time efficiently.
  9. Lets people know how they fit into the "big picture"- WHO they are responsible to in the chain of command.

You don't need a management consultant to write a basic job description. You can write them yourself, with the assistance of an office manager or other medical person familiar with the daily routines of an office. 

Redesigning Job Descriptions
 As practices grow, sometimes the job descriptions grow and change too. A practice starting out might have one "front-office" person and one "back office" person, but as your patient population mounts, you will need to add to your staff, and subdivide, reassign, or redesign duties.

As practices grow, some employees grow too. You may find that your receptionist turns out to be great with collection skills, or your LPN has been taking management courses and has become bored with her clinical duties---job descriptions help you to fit the right person to the right job, and still get every aspect of work done.

OFFICE MANAGER
 If you have a staff of more than two people, you need an office manager, someone who can tie the duties of all the staff together, keep an eye on the business, and keep things running smoothly on a day to day basis.

Where to find a manager: 

  1. Promote from within the office
  2. Outside the office. 

At any rate, the person who will be your manager needs both administrative AND clinical skills, in order to deal with ALL aspects of your practice. A person with good clinical skills but weak business management skills may have some difficulty with the financial aspects of your practice, and have difficulty working autonomously. A person with strong administrative skills but weak clinical skills may not be able to relate adequately to patient care needs, and may be unrealistic and out of touch regarding implementation of clinical policies. The best choice is a balance between the two.

This person must also have excellent employee relations skills. Education level is again according to your office's needs. Education helps, but is not the only criteria to use when choosing an office manager.

WHAT COMPENSATION WILL YOU PROVIDE?

Benefits
Most practices offer at least some level of benefits. A practice which is just starting out clearly cannot afford huge amounts for employee benefits. Excellent benefit plans can help to bolster the measly appearance of a lower hourly rate.

Some benefits are given to all employees, while others can be reserved, by your practice's policy, for full-time employees only.

BASIC BENEFITS: 

  1. Free care for employee and immediate family.
  2. Overtime paid at a certain rate.
  3. Holiday pay.
  4. Vacation pay.

MORE EXPENSIVE BENEFITS:

  1. Hospitalization insurance for employee and/or immediate family.
  2. Life insurance.
  3. Retirement plan, IRA, or KEOGH.
  4. School or college tuition reimbursement.
  5. Continuing education reimbursement.
  6. Professional fees paid.
  7. Mileage or car expenses paid.
  8. Uniform allowance.
  9. Profit-sharing.

What Benefits does the LAW Require?
 (Some of the most basic guidelines of the Fair Labor Standards Act are listed below. It is a good idea to call or write your local Wage and Hour Commission and read their materials carefully. The guidelines listed below deal with employees over the age of 18)

The law does not require that you offer pay for

The law DOES require that supply:

Call or write the Wage and Hour Division of the U.S. Department of Labor and ask for "WH Publication #1282---"Handy Reference Guide to the Fair Labor Standards Act".

COBRA Law/Continuation of Benefits
 Federally mandated "COBRA" law states that if you have hospitalization benefits for your staff, there are certain "qualifying events" that allow for your employee, the employee's spouse, or the employee's children to stay on your hospitalization benefits beyond the date the coverage would normally terminate. The law states they may continue with your plan for at least 18 months, and in some circumstances even longer. Qualifying events include, but are not limited to:

  1. an employee who is quitting, is on leave, has had hours reduced to the point they are no longer eligible for your insurance, or otherwise is leaving your employ;
  2. an employee who becomes totally disabled and can no longer work for you or anybody else;
  3. the death of an employee (the spouse and/or dependent children can then stay on the plan);
  4. an employee who is quitting or is terminated and is eligible for Medicare;
  5. an employee who is divorcing or separating from a spouse, and will lose the spouse's insurance for themselves or the children;
  6. an employee's child that has become no longer dependent.

Under these circumstances, the employee and/or spouse and/or child can stay on the benefit plan as long as they pay for the premium themselves. You may charge this person up to 102% of previous premium (the extra amount is meant to cover the administrative costs of maintaining records for this person).

All employees who are leaving your employ for one reason or another or have a "qualifying event" must be notified of this. The best way to do this is to make this a part of your employee manual, so the employee receives this information upfront and knows ahead of time that this is an available option for the future. The employee then must be re-notified at the time of a "qualifying event.

The laws and restrictions regarding COBRA law change from time to time. The company that provides your medical insurance should supply you with current regulations and regular, serial updates, and can assist you with the mandatory forms and notices necessary to be compliant with the law.

HOW MUCH TO PAY STAFF
First Considerations
 Some of your first considerations regarding payroll should be:

  1. Number of people needed to hire
  2. Job descriptions or qualifications required
  3. Reasonable wages for these positions
  4. Payroll budget
    1. To allow for reasonable wages
    2. To allow for affordable benefits

Initial Wage Setting
You can find out what the going rate is in your geographic area by :

  1. Checking with other physicians
  2. Reading classified ads
  3. Checking with colleges and universities (placement departments);
  4. Obtaining data from informational sources such as the AMA or the Medical Group Management Association or other periodicals.

Wage Structures
Employees are usually classified into one of two categories:

  1. Non-exempt---these are your employees whose pay is measured on an hourly basis. These people normally do not have supervisory authority over other workers.
  2. Exempt---these are salaried employees. They have supervisory authority over at least two or more employees, perform administrative tasks that require discretion and judgment, and have duties requiring knowledge in a specialized field of study.

Probationary Rates
It is not uncommon for a practice to offer a lower starting rate during the first 90 days of employment, and then increase this rate if the employee's progress in the probationary period has been acceptable. This lowered rate also helps you to:

  1. Recoup a portion of your losses should the employee leave or be dismissed during this training period
  2. Ease the increase in your payroll budget at a time when the new employee is not yet fully productive

Rock-Bottom Wage Rates
Keep in mind that if you offer a very low starting rate, you may be attracting applicants that could not get a job anywhere else, or that will stay with your practice only until something more lucrative comes along. A good benefit package can help to boost the image of a moderately low wage rate, but there is little that can make an insultingly-low rate look more attractive.

High, Competitive Rates If you are going to offer a high and competitive salary or hourly wage, you should require high standards and a high level of performance to justify the expense. Note: a high rate will compound and rise quickly with every merit raise given.

WHERE TO FIND STAFF
Once you have determined how many staff members you need, what job descriptions you need, and how much budget you have available for wages and benefits, you begin the process of finding applicants.

A variety of applicants suitable for medical practices can be obtained from one or several of the following sources:

  1. Walk-in applicants (self-referral)
  2. Call-in applicants (self-referral)
  3. Word-of-mouth referrals (grapevine)
  4. Employment agencies
    1. Candidate pays fees; or
    2. Employer pays fees.
  5. Medical staffing agencies (temporary or permanent help)
  6. County medical societies---similar to employment agencies
  7. Local hospitals---grapevine, retiring or relocating physician's staffs
  8. Professional organizations---usually higher-level positions
  9. Professional and technical schools (placement departments)
  10. Classified ads: public newspapers Explicit---list duties and hours. Pre-screens applicants. List name of practice and address---people often fear blind box destinations---maybe in a bad neighborhood, or maybe even the current employer! professional journals---usually for administrative employees
  11. Recruiting services---usually for high administrative employees
  12. Promotion from within

The HIRING PROCESS

  1. Hiring Laws
  2. Written Applications
  3. Prescreening
  4. Interviews
  5. Pre- and Post-employment testing
  6. Making your Choice

Equal Opportunity LAWS in Hiring
There are a myriad of Civil Rights laws at the Federal and State levels that protect potential applicants from the damages of discriminatory hiring. 

You cannot allow any of the following to influence your hiring policies: 

  1. age
  2. sex
  3. race
  4. ethnic background
  5. religious background
  6. marital status or family situation
  7. handicap.

The government of the United States has many laws in place to protect and support people seeking employment. If you breach one of these laws, "I didn't know it was law" will not hold up in court. It is important that every practice manager and every physician managing a practice be familiar with these areas of employment law:

  1. Federal employment law
  2. State employment law 

WRITTEN JOB APPLICATIONS
If a question is asked on a written job application, then the answer can be used in making a hiring decision. UNINTENTIONAL discrimination happens when an employer asks for information that tends to affect a group protected by the fair employment practice laws differently than other applicants AND does not involve a bona fide job qualification.

It is legally OK to ask for the following information, either on an application or during an interview:

  1. Name
  2. Social security number.
  3. Present address.
  4. Telephone number.
  5. Present employment.
  6. Prior employment or job-related experience
  7. Educational background.
  8. References/contacts

Questions you should NOT have on a job application form:

  1. Criminal offenses---you cannot ask all-encompassing questions about whether a person has been accused of a crime. You can ask if the person has been convicted of a crime relating to their profession.
  2. Age---unless you think the applicant is minor, this question is irrelevant. You MAY ask, "Are you at least 18 years old?" After the applicant is hired, then get their birthdate for their records. 
  3. Disability/illness---there are multiple Federal and State laws protecting people with mental and/or physical handicaps, including the Americans With Disabilities Act of 1990. You cannot ASK if the person has a handicap, nor can you refuse to interview a person solely on the basis that a handicap is present. The employer can describe the essential functions of the job, and ask the applicant whether or not he or she could perform those tasks with or without "reasonable accommodation". The applicant has to be given the chance to tell WHY they can adequately perform the job. The law prohibits discrimination against "a qualified individual with a disability". You cannot ask how many days the person was absent from work because of illness last year, but you can tell the person what your attendance requirements are and ask if the applicant will be able to meet your requirements.
  4. Marital status, spouse's employment status, questions regarding children and childcare arrangements, and childbearing plans.
  5. National origin, race or religious affiliation of the applicant or the spouse.

Application "RED FLAGS"

PRESCREENING
It is not necessary, or reasonable, to call every candidate into your office for an interview. After reviewing applications and resumes, the number of reasonable candidates can be determined. Further narrowing can be done by calling interested candidates and doing a brief "phone assessment' over the phone. By listening to tone of voice, choice of words, and other communicative skills, as well as by briefly outlining more detail about the position and schedule required, some candidates can be eliminated from further investigation.

JOB INTERVIEWS
To keep yourself out of legal trouble, you have to know how to interview job candidates carefully, so that you are not labeled as discriminatory when making your final choice.

Choosing Interview Questions
By legal standards, the questions you ask during an interview must relate to BFOQ (bona fide occupational qualifications). And your qualifications for a job should be "bona fide" also---in other words, to require a master's degree for a file clerk would not be a bona fide qualification.

During the actual interview, the above points ("items which should not be on an application form") should only be discussed if the interviewee brings them up. Again, your line of questioning should be related to BFOQ.

It helps to have a list of questions written down before the interview, rather than shooting questions out randomly. It also is helpful when it comes time to make your final decision if you have asked each interviewee the same questions.

Sample questions:

  1. Why are you interested in this job? or what about this job attracted you?
  2. What type of work are you doing now? Tell me about a typical day or week in your current job.
  3. Why are you leaving? Or, what circumstances have prompted you to change jobs?
  4. Give me an example of when you did more than was expected of you.
  5. What do you like most about your current job? What do you like least about your current job?
  6. What do you feel you could bring to this job?
  7. Tell me about your training/ or, how has your educational training prepared you for this job
  8. Tell me about your work experience.
  9. How do you set priorities and organize your time?
  10. What reasons do you believe have caused your success in previous jobs?
  11. What circumstances have caused problems in the past jobs?
  12. If you were in my place and were involved in hiring, what qualities about yourself would appeal to you?
  13. Tell me about a time when your supervisor was very pleased with your performance. OR, For what are you most frequently praised?
  14. Tell me about a time when your supervisor was less than pleased with your performance.
  15. What ideas do you have to assist private medical practices to reduce costs?
  16. How do you feel about working with medical patients and doctors?
  17. At times we've all had to work with troublemakers. Tell me about your most troublesome person and how you handled the situation. OR Tell me about the last time you had to deal with a dissatisfied, angry or unreasonable patient.
  18. Tell me about a time when you were under a great deal of pressure. How did you deal with it?
  19. Are you willing to be bonded?
  20. How long did it take for your to learn your job at _______________. Which parts took the most time? Which parts were the hardest? Why?
  21. For what kinds of things do your supervisor, other employees, or customers/patients depend on you? To what extent did you meet their expectations?
  22. When will you be available?
  23. Do you mind if we call your references/Tell me about your references.
  24. What additional information about yourself do you want me to know?

Hints for a Productive Interview

  1. Try prescreening your applicants over the phone BEFORE granting interviews. This will eliminate applicants who have misconceptions about the opening available.
  2. Be sure to allow at least 1/2 hour, privately, with NO INTERRUPTIONS.
  3. Review the job description, the resume, and the application BEFORE the applicant arrives.
  4. Phrase questions in an open-ended, positive way. This will encourage conversation rather than a yes/no response. For example, if you needed an employee willing to work extra hours, you would not want to say, "You can work overtime, can't you?' or, "Do you mind working overtime?" A better wording might be, "How do you feel about working overtime?" In this way, you will get a clearer and more specific answer.
  5. Ask one question at a time and give the applicant your full attention as the reply is given.
  6. Take notice of actions and affect as well as verbal responses. Poise, fluency, courtesy, diction, and grooming also deserve your observation.
  7. Have a copy of the job description ready, for discussion.
  8. At the end of the interview, the applicant should also be given the opportunity to ask questions.
  9. If you have a mandatory probationary employment period, be sure that the applicant is aware of this as a term of employment (see section 3, "Staff Development")

Documenting The Interview
It is VERY important that you make documentation of what went on during an interview, for three reasons:

  1. You will need these notes for comparison to choose the best candidate. You can compare how each applicant answered the questions, as well as compare past experience and qualifications. Make your initial notes descriptive, not evaluative.
  2. You may need at some point in time to be able to prove why one applicant was chosen over another. Your notes may be your best legal defense.
  3. Should this applicant be considered for employment at a later date, your notes will refresh your memory about the applicant.

Keep all records of all interviews and all resumes (whether the applicant was hired or not) indefinitely.

Do not write on the application. For legal purposes in the future, you may need to prove that the information on the application was provided by the applicant, not you. Again, you may need them for your legal defense in claims regarding discrimination, to prove exactly what happened during the hiring and interview process.

Closing Statements
When the interview has come to its completion, always ask if there is anything else the applicant would like to add or discuss. The following are samples of wording to help you bring the interview to a close:

If you're pretty certain this candidate will not be hired: "Thank you for your time. I still have a number of candidates to interview. I'll let you know when my final decision has been made, in about two weeks."
If you think the candidate is still in the running; "I'm very interested in some of the things you've told me today. I still have a number of candidates still to interview. I'll be in touch within the next two weeks."
If you think this might be the one you'll be hiring; "I'm very impressed, but I need a couple of days to complete my other interviews and make my decision. I'll also need to check your references. I'll be back in touch with you within ___days."

Resumes and References
Some candidates may inflate their resumes to appear that they are more experienced than they are. The person may say that they are a billing expert, when in fact their only billing experience was in loading charges into a computer for processing. Never hire solely from an impressive resume. Match the resume up to the application and look for discrepancies.

If the person claims to be an expert, check references, and question the person further on what his or her duties actually were.

Resume "RED FLAGS":

Always check references, if references are voluntarily offered for your inspection. Be sure that the applicant has given you SIGNED PERMISSION to check references.

PAST BEHAVIOR PREDICTS FUTURE PERFORMANCE. Chances are overwhelming that a person will not:

  • perform any better

  • work any harder

  • act any differently

for you than he/she has done for others in the past.

ENTRANCE, MEDICAL, and SKILL TESTING
Some offices actually require a written test or skills checklist before hire, to assess what specific skills and abilities the person truly has. For example, a sample of transcriptionist work, correct medical word spellings for a secretary, etc.

Pre-employment medical testing and drug testing cannot be routinely required of an applicant unless the applicant has received a firm job offer from you.  The offer of employment can be made contingent on the passing of drug tests or medical tests that are related to performance of the job (for example, a TB test or a VDRL test).

MAKING THE CHOICE
Most physicians or managers bring each applicant in for a initial interview, and then narrow the field down to two or three choices for secondary interviews. From the secondary interviews, you may be able to make a final choice, and you may wish to interview that final choice one final time.

Even if the applicant seems excellent, it is best not to offer a job on the spot. The person's references may not check out, or perhaps the next applicant would be even better for the job. Avoid making a decision based on the person's outstanding personality.

When comparing one interviewee to another, you need to consider:

Rejected Applicants
If you tell an applicant that you will notify them by a certain date regarding their interview, follow through with this promise. It reflects very badly on your entire practice if you don't, and is just plain discourteous.

A rejection in writing should include:

  1. Thanks for coming in for the interview.
  2. An offer to keep resume or application on file.
  3. Reason (s) why another unnamed applicant met the criteria.
  4. Encouragement regarding the applicant's stronger points.

Chapter 2---PERSONNEL POLICIES
AND RECORDKEEPING FOR YOUR PRACTICE

HOW DO YOU DEVELOP POLICIES FOR YOUR PERSONNEL?
If you have never managed any staff or been responsible for employees, the task can be bewildering and frightening. Staffs don't normally work well on "automatic pilot"--- they need a leader. You can learn more about staff management by doing some reading. Some excellent sources of information of staff management include, but are not limited to:

  1. Medical Economics Magazine
  2. AMA Publications
  3. AAFP Publications
  4. MGMA Publications
  5. "The Doctor's Office" Newsletter (supplied by admitting hospitals)
  6. Physicians' Management Magazine
  7. Human Resource management textbooks
  8. Federal Register (selected dates)
  9. Wage and Hour Commission Publications
  10. Wall Street Journal
  11. Personnel Journal Magazine
  12. Chamber of Commerce Publications
  13. Commercially advertised seminars

IMPORTANCE OF STRUCTURE
Start by putting into writing what you would like for your employees to know, and what rules you would like them to abide by. This is much better than "making up the rules as you go along"! 

The purpose of well-thought-out policies is to:

  1. encourage consistent understanding among the entire staff,
  2. forestall misunderstandings
  3. decrease staff stress by having them know what is expected (most medical professionals are very poor mind readers)

WHAT MAKES A STAFF WORK WELL TOGETHER?
 There are many factors that help a staff group to work well together. The primary ingredients are:

COMMUNICATING YOUR POLICIES

Practice Philosophy
 You may already have in mind what your personal philosophy is regarding patient care. You also need to consider, if you have not done so already, what your overall practice philosophy will be toward patients and staff also. Example:

"PREFACE TO PERSONNEL: We would like to welcome you as a member of the Typical Family Practice, Inc. health care team. We use the term team because the entire staff functions as a team in order to keep things running smoothly. Although each staff member has specific duties, assisting one another as needed is a necessary part of teamwork."

GOAL SETTING: 

Goals are good, whether for your own personal performance of for the entire practice. Set a common goal every member can shoot for. Attitudes affect your performance, the performance of coworkers, and in turn, the performance of the entire practice.

Example of staff goals for a practice:

  1. To provide the best medical care possible to our patients and build a practice which allows us to provide this care in a comfortable and pleasant setting.
  2. To treat every patient with kindness, respect, dignity, and courtesy---and to let each one know they are important to us.
  3. To serve the community through preventative medicine and other projects.
  4. To have highly motivated staff who are interested in their work and in their patients.
  5. To have a smoothly functioning practice in which everyone works together in a spirit of harmony and cooperation. The pace should be efficient, making best use of everyone's time, without creating a sense of hurry or confusion.
  6. To have a practice where we can meet patients needs and exceed their expectations, remembering we have NOTHING without our patients.
  7. To earn a fair monetary return for our efforts and investment.

THE EMPLOYEE MANUAL
 Employee manuals are written to explain the policies and benefits of employment with your practice. This is also a form of "preventative management", to clarify your policies and avoid misunderstandings.

Wording the Manual
 "The employee manual document is in no way an employment contract, nor should it be construed to be one"---and this statement should be written in your manual. These are strictly employment guidelines so that you can have mutual understanding between employees and management. (see also At-Will Employment)

Start by making a policies checklist, and draw up some kind of a simple outline of the subjects. You may want to write the whole thing yourself, have your manager write all or part of it, or have your entire staff assist with creating this document. You may also want to look at examples of manuals from other practices or companies, and word your manual in a similar fashion.

The manual should be updated as deemed necessary by the management, and should have insertions and deletions as needed.

INFORMATION REQUIRED BY LAW TO BE POSTED
Federal and State governments mandate that certain information must be posted in written form (usually in the form of a poster) somewhere easily visible to employees in your practice The state postings vary from state to state. This requirement is mandated to all kinds of business, not just medical facilities.

Check with the Federal Wage and Hour Commission to find out what the latest requirements are for employee postings. The address and number can be found in the phone book, or a librarian might be able to assist you. You might also want to look for a state listing of a similar agency to tell you what the current state requirements are for postings. Both Federal and State agencies can usually provide you with one copy of every required poster. There are also commercially prepared posters which condense several posters into one handy plain or laminated poster.

PERSONNEL RECORDKEEPING

Mandatory Information
 The Fair Labor Standards Act requires that certain kinds of information be maintained on your employees. These records are required to be maintained for at least four years. (maybe more, varies from state to state) This information does not need to be contained in a specific form; it can be in the record style of your choice as long as it contains all the information.

  1. Name and address.
  2. Birthdate, if under 19 years of age.
  3. Sex.
  4. Occupation.
  5. Time of day and day of the week the work week starts.
  6. Hours worked each day AND week

Mandatory Personnel Records
 There are certain forms and information that are required BY LAW to be kept on all employees.

  1. As of 1998, the law requires that an EMPLOYMENT VERIFICATION form be filed within 10 days of employment.
  2. W-4 form, indicating how many tax deductions the employee wishes to have withheld from his or her paycheck
  3. I-9 form, proving citizenship or alien status (must be kept for at least three years that employee is working and for at least one year after termination)
  4. OSHA bloodborne pathogen records, including:
    1. Proof of disclosure and instruction
    2. Proof of Hep B vaccine administration or written refusal of vaccine
    3. Documentation of bloodborne pathogen exposure or other related incidents or injuries.
    4. Documentation of any other injury on the job.

Optional Personnel Records
 There are other records which are not required by law but may protect your case in the event of a lawsuit. It's a good idea to keep a complete employee file, just as you would keep a complete patient file. "If it's not written, it isn't done". Other items, beyond mandatory information, might include:

Personnel Forms
 Several kinds of forms are needed in order to keep accurate and complete personnel records. To protect your practice against suit, job descriptions, performance evaluations, documented reprimands, and termination notices should be kept on file for at least three years.

PAYROLL RESPONSIBILITIES AND RECORDKEEPING
 The Fair Labor Standards Act requires you as employer to keep various kinds of documentation as proof of your payroll.

  1. Administrative information---name , address, social security #, occupation, and birthdate if the person is under 18 ONLY.
  2. Workweek definition---day and hour that the workweek begins and ends.
  3. Individual payroll totals---hours worked each workday and workweek.
  4. Categorization of pay rates---how many hours for each individual were at a regular rate, how many hours were overtime.
  5. What deductions were taken to calculate each person's payroll, and what time period this pay covered.

All About OVERTIME PAY---the facts:

  1. The law does require that you pay time-and-one half if an employee works more than 40 hours in ONE WEEK. If you pay every TWO weeks, the weeks must be totaled separately---for example, if the employee worked 30 hours the first week of the pay period and 50 hours the second week of the pay period, you would owe the employee overtime for the second week. WEEKS CANNOT BE AVERAGED.
  2. Overtime, according to wage and hour laws, is determined by calculating how many ACTUAL HOURS have been worked in a week. VACATION days, SICK days, PERSONAL days, etc. are not considered "actual hours"---they are "benefits". For example, if an employee worked thirty-two hours in a week and took sixteen hours of vacation pay, NO OVERTIME would be owed. 
  3. The law DOES NOT require you to pay overtime if the employee works more than eight hours in a day. You could ask the employee to work around the clock, and as long as the total does not exceed 40 hours in one week, no overtime is owed.

Mandatory Deductions
The following are items that you as an employer are required to withhold from your employees' paychecks:

  1. Federal income taxes, according to the number of deductions the employee has listed on the W2.
  2. FICA/Medicare tax---ask your accountant about what % to withhold.
  3. State Tax
  4. City or municipal taxes, if any.

Calculating the Payroll---four options

  1. Manual system for calculating payroll can be set up for your use by your accountant. If you have a small number of employees, this may work, but your accountant will still have to prepare portions of the records
  2. Accountant doing the payroll (very expensive)
  3. Payroll service (such as ADP or Paychex) to calculate your payroll. They will also take the responsibility of calculating payroll taxes for the practice and completing and submitting those forms. The money is taken out of a practice bank account.
  4. Software to do records and payroll calculation in-house.

Keeping Control of Runaway Personnel Expense (payroll and benefits)

  1. Careful monitoring of OT, juggling staffing to cover peak hours,
  2. Changing of job descriptions rather than hiring additional help.
  3. Comparing costs for payroll done in-house or by payroll service VS being done by accountant. Manually if a small office.
  4. Giving "professional courtesy" as a benefit
  5. INSURANCE OPTIONS:
    • changing deductibles and coinsurance
    • use of part-time employees (for which there is no insurance as a benefit) or "job sharing", "splitting" position
    • insured reimbursement plans---
      • "Cafeteria" plans; employer CO-pay Section 125 (employee chooses a $ amount of benefits from a list of benefits)
      • COSE or ARDB insurance plans, Chamber of Commerce Plans
      • employee is given an allowance to go out and get their own coverage

Chapter 3---HUMAN RESOURCES DEVELOPMENT

THE NEW EMPLOYEE

ORIENTATION
 When you bring a new employee into your practice, you must convey to that person what your company's philosophy is, what kind of attitude you expect, what level of service you wish the practice to provide, what image the practice is to reflect, and how the person fits in the "big picture". In order for a new employee to make good business decisions while working for you, the employee has to know how your practice "thinks".

Benefits of Effective Orientation
 New employees left to their own devices regarding orientation and decision-making obviously experience higher stress levels than those who are oriented completely and properly. A good orientation program helps a new employee feel like a team member rather than an orphan, right from the start.

The First Day
 On the first day, a new employee should be provided with the following materials:

The new employee should also have the following verbally explained or demonstrated:

An employee in orientation should be encouraged to ask questions, explore rooms and cupboards, and to confer daily with their supervisor to assess progress. A scavenger hunt is one way to ascertain whether an new employee knows where everything is

You might want to have your admitting hospital give your new employee a tour of the hospital, to meet the people, see the departments they will be sending your patients to, and to show your new employee what services your admitting hospital has.

Orientation Checklist
An orientation checklist is a good method for familiarizing a new employee with what they need to know. This list also helps the employer not to forget any crucial information. You might want to create a generic orientation list that could be used by any new employee (excluding things that are not applicable) or a specific checklist for each type of position.

Supplementary Materials
You might also want to use additional audiovisual materials, such as motivational cassettes and videotapes to supplement your orientation. Such materials can help to reinforce your "patient oriented" atmosphere. Special tapes can also help to improve telephone skills and patient relations skills. Some tapes are available free from pharmaceutical reps.

Assessing Orientation Progress
As the orientation progresses, you might want to periodically "test" on such subjects such as contents of employee manual, company philosophy, emergency procedures, etc.

If you are using an employee manual, you might require that it be read fully by the end of the first week, and require a signed form stating it has been read and all immediate questions have been answered.

If you are using an orientation checklist, you might want to require specific items to be accomplished by specific dates. Procedures done satisfactorily can be initialed by the person assisting with the orientation. You may want to allow the new employee to do certain jobs independently once they have been mastered and "signed off".

ESTABLISHED EMPLOYEES

STAFF DEVELOPMENT
 In this text, the term "Staff Development" does not mean to develop new sources of finding staff. It means take the staff that you have and help them develop into the best employees possible, and the best professionals personally. Your staff development plan for current employees will also provide a basis for enriching your future employees. Staff development programs can take many forms, and can be individualized to the needs of each practice and its individuals. Some practices have no staff development plan at all, and studies show that these practices have a higher level of attrition than practices that have taken the time and money to invest in the enrichment of their staff.

Elements of a Staff Development Program
 Staff Development goes much further than "continuing education" or inservices, but can include both. 

Some practices require that each staff member, from the file clerk to the medical director, be involved in X number of educational hours (formally or informally) to continue employment or be considered for additional wage increases. There are some costs to some forms of staff development, while others are of little or no cost to the practice other than time expended.

Some types of staff development might include:

  1. Inservices on equipment and procedures.
  2. Lectures and discussions regarding diagnoses or conditions, to promote better understanding of patient situations. Some practices have a "disease of the month" theme, and have short weekly lectures to the staff pertaining to the diagnosis.
  3. Training to assist staff in patient education. This may include suggested ways to present information to patients, or to train patients in medical
  4. Procedures, such as insulin injection, dietary choices, explanation of surgical procedures, etc.
  5. State-mandatory contact hours for nurses.
  6. Presentations by pharmaceutical reps regarding uses of medications.
  7. Formal seminars on multiple aspects of a broad subject area.
  8. Guest speakers from institutions or social service organizations, explaining the purpose and scope of their services.
  9. Videotapes and audiocassettes on various subjects.
  10. Workbooks and modular training sessions for self-study and self-enrichment.
  11. Nationally marketed lectures and discussions.
  12. Conventions of professional medical groups.
  13. BCLS, CPR, ACLS, or other emergency training.
  14. Group problem-solving or "brainstorming" among members of the staff.
  15. Self-directed reading or independent study.
  16. Hospital or clinic sponsored lectures, discussion groups, lecture series, and professional organizations.
  17. Trade shows (vendor sponsored)
  18. Insurance-sponsored lectures and programs.
  19. Notebook of articles pertaining to activities of the practice.

DEALING WITH CHALLENGING EMPLOYEES

Most Common Employee problems to deal with:

The Special Problem of Expressing Anger During the Workday

Reasons for Performance Problems: Expectations, Skills, Conflict

Performance Problems: Health, Family, Child Care

Creating a Positive Work Environment

Productivity and Morale---starts with YOU, but also applies to each employee

Don’t Ignore Problem Employees

Responding to Difficult Employees

Offer suggestions, and ask for theirs.

Consider the Employee’s Side

Look Before you Leap (firing someone) (read upcoming section on "firing")

SUMMARY of "Dealing with Difficult Employees":

COMMUNICATIONS AND PROBLEM-SOLVING

STAFF MEETINGS
 Many practices try to meet with their staff on a regular basis to discuss policy, problems, PR, educational matters, and the like.

Attendance

Ground Rules
 Encourage their input on subjects and matters to be discussed at future meetings. You might want to get their suggestions several days or weeks ahead, and hand out a tentative agenda to the staff several days before the meeting.

Some staff meetings have the reputation for being "gripe and grudge" sessions where the group is grilled on everything they have not done properly. Set some rules for the meetings, such as forbidding personal verbal attacks against one another.

If you are having a particular problem in your practice, an impromptu meeting might need to held right away.

Retreats
 Some practices also hold retreats to bring their staff together, usually lasting a full day or more, at a site other than the practice site itself. Much can be accomplished away from the stresses of the work environment, in a quiet, non-rushed, casual setting.

Day-to-Day Communications
 It's not always easy or convenient to have a meeting to discuss every situation or change in your practice, yet it is necessary to make sure everyone is getting the same information. For these situations, some means of passing the information is necessary.

PERFORMANCE EVALUATIONS

 If your practice is fortunate, you will have a staff full of excellent workers who all get along well and have few problems. Unfortunately, this is not realistic at all.

Some practices look over inefficient and ineffective workers in order to avoid conflicts and confrontation, but burying the problems will only make matters worse---productivity will drop, and morale will go down the tubes. Employees may assume that the manager's silence means approval. Complacency is not the answer. Firing the offenders may not be the answer either. Change is unlikely without feedback.

Imagine trying to fly a plane without instruments or feedback to tell you if you are on course. This is the same situation when you allow employees to function with no feedback.

How Often?
 Formal feedback occurs in practices usually once a year, but general feedback on performance should be continual throughout the year. Day-to-day problems should be taken care of immediately, or as soon as possible, not hoarded up and dumped out on an evaluation date six months in the future. If you are handling day-to-day behavior and problems appropriately, as they come, there should be no surprises or big revelations at the appraisal interview. At least once a year is appropriate, more often if the particular employee is performing only marginally. Reviews are often linked to salary reviews.

WHY MANAGERS DREAD GIVING PERFORMANCE APPRAISALS

WHY STAFFERS DREAD RECEIVING PERFORMANCE APPRAISALS

confrontation

personal attack

subjective comments

look bad to boss

difficult to judge people

fear

grading system

emotional experience

consequences

unrealistic expectations

fear of offending

waste of time

lack of confidence

  

What an EFFECTIVE Evaluation Includes
Few people really look forward to an evaluation in a positive manner, but a good employee evaluation should serve at least three purposes:

  1. To emphasize and show appreciation for strong points. EVERY employee needs positive feedback in order to know that their work is noticed and appreciated. Again, do not hoard your praise and "thank yous" for the evaluation date---show your appreciation whenever the situation warrants it. Generally, employees try to do a good job, but self-esteem may suffer if no appreciation is shown for their efforts.
  2. To show ways of improving mediocre points. Few employees are outstanding in absolutely every aspect of their position.
  3. To show where weak points are, so these areas may be corrected and improved.

If you must give a less-than-satisfactory, average, or mediocre rating or negative feedback to an employee in a certain area of evaluation, provide also for the employee what your standards are, why their current level of work does not meet this standard, and TOGETHER work out a measurable and noticeable means of improvement. Don't point out a problem without planning the solution. Set goals and deadlines for their achievement.

Don't curse the darkness without providing a light.

Documenting and Measuring Performance
 Some kind of a form should be used to evaluate performance, so that a copy can be kept permanently in the employee's file. In this way also, you can document that an employee has or has not made needed improvements in reportedly weak areas.

Some areas of evaluation might be:

  1. Neatness/appearance
  2. Promptness/attendance
  3. Attitude/incentive
  4. Clinical ability/performance
  5. Self-stimulated education/continuing education
  6. Accuracy/detail
  7. Patient relations
  8. Effort

Some systems grade from 1 to 10, others from poor to outstanding. There should be room on the form where the evaluator can write comments as to WHY a certain rating was given, or to elaborate further on an area. 

You can create you own form on a typewriter or computer, or you can purchase forms from office supply catalogues, medical supply vendors, or other sources.

Why Bother Writing Your Evaluation Down?
 Writing down your evaluation helps to gather your thoughts regarding the employee's performance in a concrete way. By recording, you also can distinctly compare performance from one point in time to another point in time. Your employee can reflect on what was written down, not just on the emotions of the evaluator at the time.

The written evaluation should be presented to the employee in a private manner, and discussed, not just read. There should be two-way communication during a review, so that the employee can also give you feedback.

Also in regard to legalities, you need to document why levels of raises are given. If an employee is disgruntled over the amount of a wage increase, and your documentation does not substantiate one wage increase versus another employee's increase, you could find yourself in trouble. Your paperwork needs to PROVE and EXPLAIN your actions.

The Law and Performance Appraisals
 There is no law that says that you HAVE TO DO performance appraisals. However, performance appraisals, just like other employment decisions, are subject to state and federal labor laws. They must be administered FAIRLY in order to avoid charges of discrimination.

Some guidelines to help you avoid legal nightmares:

RAISES and ADDED COMPENSATION
 Some doctors have no real system for deciding when and how much to raise employees' salaries. You also cannot expect staff to stay with your practice if their tenure and loyalty is not compensated...they may soon be seeking "greener pastures". Even loyal employees have families to feed and personal financial needs.

On an average, most practices review salaries AT LEAST once a year. Employees whose pay rates are not reviewed regularly may wonder if the doctors know about or appreciate what they do for the office---and this can make for poor morale in your office.

How Much Raise?
 It is standard practice NOT to give each person on staff the same amount of raise. Develop a raise system to that will:

  1. keep up with the cost-of-living in your area (expenses may be rising for your practice, but expenses are rising for employees) 
  2. compensate according to performance.

Clearly, your employees who give you an average amount of effort should NOT receive the same rate as those employees who pour their whole heart and soul into doing an outstanding job for your practice.

If you cannot give a raise to your employees (can't afford it at this time, poor year for practice, heavy expenditures, etc.), be sure the employees know WHY, and let them know they will receive compensation when things become more solvent (follow through on the promise). If they know the REASON behind withholding the raise, they may be more understanding.

Profit-Sharing and Incentives

  1. General Profit Sharing
    • Some practices have profit-sharing plans as a means of added compensation and incentive. The purpose is to make the employees feel as though they have a true stake in the success of the practice. This encourages staff to keep on top of billings, watch expenses (shop for prices and discounts) , monitor waste, and to more actively market the practice through their actions.
    • A profit-sharing program can work well because every department in some way, great or small, contributes to its success, and reaps rewards. Some hard feelings can be generated if one department feels they did all the work and all the departments receive the rewards.
    • If your practice decides to expand services or hours, the staff who are on such a program can see these changes as ways to increase revenue, not just as added workload.
  2. Incentive Programs
    • Some practice groups use incentives as a means to boost performance in specific areas. Usually these incentives are geared toward accounts receivable matters, such as collection on old accounts and decreases of average "days in receivables" for unpaid accounts and insurance claims. In some practices, incentives help to increase general practice profitability.
    • Guidelines must be set for A/R incentive programs, because an overzealous staff may put extreme pressure on patients to pay so that goals can be obtained.
    • Departments not involved may be disgruntled because underproducing departments are being "bribed" to do what they should have been doing all along

WAGE/RATE CONFIDENTIALITY

EMPLOYEE TURN-OVER

Although your focus should be on attracting and maintaining patients, it should also be on attracting and maintaining staff. Attracting and maintaining excellent staff gives your practice an edge over your competitors. Also it is expensive and disruptive to train employees, only to have them leave.

Do a little informal analysis on employees who decide to leave. Do an "exit interview" to find out how they felt about how they were treated while with you, satisfaction with job, rates of pay, etc.

  • The "Keepers"
    • For the ones you hated to see leave, find out why did the "keepers" want to leave. Was it for more money, better recognition, relocation, better hours, less of a commute, better working conditions, different job description, or what?
  • The "Not-All-That-Sorry-To-See-You-Go" Leaving Employees
    • These folks rate a little analysis too. Were they just bad hires, and who chose them? Was a background and reference check done? Did something happen in the workplace that affected their attitude toward the practice and the management? Did communication with this employee break down at some point? What could be done differently to prevent similar problems with other e