Program Success
By VISIONS staff
When it comes to sports championships, the team with the best players does not always take home the trophy; the team with the best team invariably does. This adage can be applied to occupational health as well.
But how does a program get a great team? If there was a formula, it would be something like this: Create and follow a staffing plan, hire wisely, train properly, monitor effectively, and adjust as necessary.
Creating A Staffing Plan
Exceptional staffing rarely happens on its own; 99 percent of the time, it requires a strategy. As part of an annual plan, for example, a program should focus on trends such as volume variance by weekday, time of day, and season. A plan can begin with a projection of a core minimum staff such as a front-desk person, providers, and billing personnel in order to function minimally. Then more staff can be added as necessary to meet upticks in volume.
Deborah Borisjuk, associate director with Yale-New Haven’s Occupational Health and Urgent Care, begins her staffing plan by covering the basic positions (e.g. physicians, nurses, L.P.N., M.A.s) and trains M.A.s to do clerical tasks.
Hiring
Hire well and you will have less difficulty down the line. According to Donna Lee Gardner, R.N., M.S., M.B.A., senior principal with RYAN Associates, a program should seek staff with a strong affinity for customer service as well as appropriate credentials and certifications. Ms. Gardner advises programs to “go beyond asking applicants about their customer service ethic and ask hypothetical questions.”
Brenda Jacobsen, C.E.O. of the 14-clinic Florida-based Lakeside Medical Centers network, noted the importance of hiring exceptional front desk personnel is often minimized. Mrs. Jacobsen cautions, however, that the marketplace is becoming more and more of an employee’s marketplace; many other organizations are looking for skilled medical assistants with the same persona and qualifications occupational health programs are looking for.
Staffing should be as flexible as possible. For example, two part-time staff are usually more valuable than one full-time staff, providing greater flexibility to staff up or down as necessary. Ms. Gardner cited the “school mom” as an intriguing candidate who could be at work between 9:00-2:30, often during peak clinic hours.
Dr. George Pappas is the co-founder of Tyler Medical Services, a two-clinic occupational health network based in suburban Chicago, established in 1989. Dr. Pappas said his most daunting challenge for the past 26 years has been finding qualified staff, that is, personnel who not only have the requisite skills for their position but are in line with the clinic’s underlying mindset and philosophy.
Dr. Pappas notes that staffing models have changed over time. “At one point it was more about using occupational health nurses; we have found that it is easier to find motivated certified medical assistants (CMAs) who are less costly and generally amenable to being cross-trained.” Dr. Pappas said physician colleagues in his area are sometimes aware of candidates who might be suitable for his program. Local colleges have also been helpful.
Yale-New Haven’s Ms. Borisjuk looks for applicants who are experienced multi-taskers, who have customer service experience, and whose capacity for teamwork can be vouched for in references.
Training
Programs should offer orientation and/or refresher training that provides in-depth descriptions of its service lines. For example, all staff should learn about the complexities inherent in injury management––including the relevance of environmental factors. Programs should also provide customer service training to all staff annually, largely based on the findings of patient and employer assessment data.
When she needs to hire a provider, Bernyce Peplowski, M.D., vice president of the U.S. HealthWorks Medical Group, looks for five traits. “You need to get a provider who understands and believes in the value of return to work. The provider should also practice minimal use of narcotics. Low utilization is critical to getting the patient back to work and back to life,” she said. “The provider should also understand ‘total claims costs.’ Though a program may bill $300 for services, if the claim was not closed to allow the patient to return to work, we are costing the employer money.”
Negotiations with physicians and medical directors, who historically consume the largest portion of a program’s budget, require creativity. An ideal package might include a reasonable salary plus incentives based on productivity, patient satisfaction, and clinical outcomes.
Dr. Pappas asks new hires to learn one task at a time, to shadow senior staff from the outset and “break in” over a 90-day introduction period. He notes that “given all of its inherent rules and regulations, occupational health is a comparatively slow learning process.”
Mrs. Jacobsen considers training an ongoing necessity and challenge. “There’s a big disconnect when someone new comes in. They want to learn as quickly as possible and we are constantly adjusting our training [procedures to] new [employee’s] desire to contribute right away.” Mrs. Jacobsen advises programs to find ways to help new hires feel less burdensome in their early training days.
Staff Moniroting
A key to efficiency is noticing when your program is overstaffed or understaffed. Productivity indicators can be invaluable when it comes to this tricky issue.
Productivity indicators use a blend of national standards such as the NAOHP’s productivity standards, and program-specific history, to identify how many personnel are needed to address a certain volume of patients. Understaffing is suggested when a clinic experiences shorter treatment times than standard and overstaffing is likely when you consistently experience longer treatment times. Productivity indicators can tell you if you need more (or less) staff and what type of staff you need (or do not need).
In addition to routinely assessing staff productivity, Ms. Gardner suggests clinical staff be routinely assessed for their history of prescribing narcotics, referring work injury patients to physical therapy, and clinical outcomes.
Mrs. Jacobson’s Lakeside network evaluates new hires weekly at the outset, then monthly. Formal evaluation forms are filled out by the staff member’s manager and colleagues, as appropriate. According to Mrs. Jacobsen, the new hire “must prove [themselves] to be a good fit within 90 days, so our evaluation process is particularly aggressive in the beginning.”
Dr. Pappas monitors a number of measures daily such as drug-screen collections. He looks for patterns and then provides more training if necessary. For example, he asks staff to mark off daily supplies to make sure they are not missing charges; the billing department must know what has been ordered and what to charge.
Staff evaluation is not always a one-way street. It behooves a program to recognize personnel in unique ways and to do it frequently. Mrs. Jacobsen wants all of her staff to have a sense of accomplishment just getting through the day. Lakeside uses different programs to identify and acknowledge effort on a daily, monthly, and annual basis. Rewards tend to be more symbolic than monetary. “We don’t want to nurture an environment that is overly reliant on [monetary rewards.]”
Adjusting For Anticipated Fluctuations In Volume
Seasoned operators note that flex time is key. As many clinicians as possible should be available for fluctuations in their work schedule, be it daily, seasonally or to fill in during vacations or unanticipated lost work time. Too often, the horse wags the tail by inefficiently scheduling staff according to what works for them. Ms. Gardner advises committing to a staffing plan based on your projected volumes, not your staff’s work-hour preferences. At Yale-New Haven, Ms. Borisjuk makes judicious use of per-diem providers to smooth out variations. Looking back, Tyler’s Dr. Pappas opted to address volume downturns less by downsizing and more by increasing his clinics’ emphasis on cash-based services such as school, immigration, sports physicals, and immunizations like hepatitis B and flu shots.
Staffing For A Blended Clinic
Staffing a blended occupational health/urgent care clinic presents opportunities and challenges. Different mindsets are associated with each specialty and both sides of the house should be cross-trained with these in mind. For example, clinical staff who have occupational health backgrounds and training must adapt to a patient-centered focus rather than the environmental causation inclination that’s endemic to occupational health.
Contributors to this story were asked to share their most edifying staffing lesson. Mrs. Jacobsen said: “With everything changing as fast as it is, especially talent, I’ve realized that our team is our most important resource. There is nothing more important to us than having the right people who are happy and feel qualified and trained.”
As a clinic owner, Dr. Pappas noted cost issues. “Unlike a large network; cash flow is tighter and particularly critical for us. We now understand seasonal staffing; we maintain a low census policy. When busy, we can offer overtime and during downtimes, we cut back hours for administration as well as clinical personnel. On the other hand, benefits are better protected for variable hour staff by using a 32-hour-a-week minimum employment threshold.”
In turn, Ms. Borisjuk said she has learned to use staff to the top of their scope of practice. “For example, you do not want to use physicians for tasks that can be addressed effectively by nurses.”
The staffing cycle, from hiring to training, to monitoring, to motivating, to scheduling, is the foundation of a program’s success, yet too often, it’s given short shrift.
