By Phyllis Hanlon
One of the most critical parts of running of an occupational medicine clinic is assembling a compassionate, qualified, and efficient staff that will deliver first-class patient care in a timely manner; to do this right requires thought, patience, due diligence, and particular attention to the bottom line.
Salaries exhaust more than 55 percent of a typical occupational medicine program’s budget experts say, so careful consideration of the people you hire and how you compensate them will make a big difference in your bottom line.
Negotiations with physicians and medical directors, who consume the largest portion of a program’s budget, take creativity. An ideal package might include a reasonable salary plus incentives based on productivity, performance, and clinical outcomes.
THE “PERFECT” MODEL
Donna L. Gardner, R.N., M.B.A., senior principal at RYAN Associates, said no two programs look alike. Factors like location and market determine the staffing and competency level a program needs. “If the program is in a high industrial area with big chemical and research plants, you’ll have to have people on board who know about OSHA regulations. They need to be highly trained,” she said. “If this is not a high-tech industry area, your practice will have a different makeup. Fewer technical staff will be required. But make sure you have the right people to do the right job with the right credentials.”
Patient volume also drives staffing decisions, though a common model will include a physician, nurse, nurse practitioner (N.P.), physician assistant (P.A.), medical assistant (M.A.), technicians, and/or front office staff.
One of the most important considerations in hiring is compensation, i.e., what your budget will allow. The bi-annual national survey from RYAN Associates offers some guidelines. In 2012, the mean total compensation for occupational medicine medical directors was $210,465. Most programs offered between $200,000 and $250,000, while 10 percent paid between $150,000 and $174,999.
Twenty-five percent were contract-salary only, while 24 percent received a salary and incentive pay. Ms. Gardner recommends programs look for the best possible candidates at the best possible price. For instance, a registered nurse earns roughly $10,000 more than a licensed practical nurse, so opting for the latter puts less strain on the bottom line.
THE IDEAL DOCTOR
Bernyce Peplowski, M.D., vice president of U.S. HealthWorks Medical Group, looks for five traits when hiring an occupational medicine physician. “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 living,” she said. “The provider should also understand about ‘total claims cost.’ A program may bill $300 for services, but if the claim was not closed to allow the patient to return to work and productivity, we’re costing the employer money.”
Dr. Peplowski said judicious use of referrals is another sought-after trait. “Some providers give up on the patient and send him to a surgeon right away. This delays return to work.”
Additionally, an occupational health provider should demonstrate the same level of empathy as a family practitioner would. “Occupational medicine [providers] sometimes [remain] aloof. But the doctor [should] make me feel warm and fuzzy.”
Having patience is key. “It’s worth waiting for the right person,” Dr. Peplowski said, adding that if she finds a physician with the above qualities, she will do one-on-one training.
Though board-certified occupational medicine physicians are ideal, according to John Braddock, M.D., CEO and medical director at Sendant Health in Lake Oswego, Oregon, they’re not always available. “If we can’t get that person, [we’ll] lean heavily toward a doctor board certified in emergency room medicine,” he said. “They are used to simpler procedures, like lacerations, strains, and sprains.” However, he pointed out that some ER doctors take a longitudinal approach and have difficulty adjusting to the occupational medicine model. “As soon as I see a patient, I begin laying out a path, a course of treatment that will help get him better and back to work. It’s a tough transition for some ER docs,” Dr. Braddock said.
An occupational medicine physician should expect his day to include physical exams and trauma care and to stay at work beyond five o’clock for paperwork and phone calls. “They should see three to three-and-a-half patients an hour,” Dr. Peplowski said.” “If they see fewer, it may not keep the lights on. If they see more, they won’t be giving good services.” Granted, there are situations in which patients require more time, such as evaluations for toxicity, but the majority of visits will involve ankle and back strains and Department of Transportation (DOT) physicals.
ANCILLARY STAFF
Occupational medicine programs demand richer ancillary staff than family medicine, Dr. Peplowski said, citing a report from the U.S. Department of Health and Human Services (HHS http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf).
That study found occupational health takes 26 percent more effort from its providers and ancillary staff than family medicine requires from its employees.
Danielle Anderson, M.B.A., program director, of WorkNet Occupational Medicine in Reading, Pennsylvania, tries to maintain a high enough staffing level to provide good and necessary services, satisfying patient expectations, yet low enough to realize a profit. “You need to find that sweet spot, a hybrid of productivity reporting, wait times, and financial consideration when evaluating the labor lines,” she said.
“We [use] a physician extender––a P.A. or M.A.—and a medical director who is an M.D. or D.O.,” she said, noting that this configuration makes financial sense. “We can use a mid-level staff person under a D.O. or M.D.”
Nurse practitioners are less expensive than physicians and just as capable, Dr. Braddock said. “The downside is that you only get 80 percent reimbursement from the insurance company for the nurse practitioner’s services. The nurse practitioner is also restricted to the first 90 days of care.”
M.A.s are a good option for an occupational medicine program since they typically wear several hats, according to Dr. Braddock. “I wouldn’t hire an M.A. though unless she was certified for audiology or in the process of getting certified,” he emphasized, adding that he expects M.A.s to also be Breath Alcohol certified (BAT).
In addition to P.A.s and N.P.s, some programs now employ physical therapists. “We use P.T.s as extenders,” said Dr. Peplowski. “They can’t write prescriptions or suture, but they do an efficient exam regarding the patient’s functioning. A program should allow the P.T. to become part of the diagnostic and coaching team.”
The addition of a P.T. may allow practices to increase productivity and revenue as patients rotate from one provider to the next, Dr. Peplowski said, citing a University of Utah study by Julie Fritz, (https://www.archives-pmr.org/article/S0003-9993(13)00029-4/abstract). “Her study indicates that when a P.T. sees a patient within the first two weeks and starts interventions, the total care cost is $2,700 less.”
Regardless of staff mix, all employees need to understand the importance of a 45-minute in-and-out time to ensure patient and client satisfaction, said Ms. Gardner.
DUE DILIGENCE
Hiring the wrong person can tax the budget, but full background checks prior to hire will help you avoid mistakes. “Call up the references and ask questions for every staff position, from the secretary to the biller to the physician,” Ms. Gardner said, adding that licensure, personality, and attitude should be evaluated during the vetting stage.
Dr. Anderson stressed the importance of a thorough, extensive interview process. “When looking for
an M.A., make sure the person comes from a decent proprietary school or college that offers a certificate or degree in medical assisting,” she said. The school’s reputation and externship opportunities will give you a good idea of the candidate’s academic foundation.
A phone interview provides bottom-line information, such as where candidates live and their expected
salary range. “You’ll also find out if the person has good communication skills.
Patients, employers, workers’ comp companies, and adjusters call often so there is much work on the phone. If the person is silent during much of the call, it’s not a good sign,” Dr. Anderson added.
Once the candidate passes muster during the phone interview, it is time for two face-to-face interviews: the first to evaluate skills and experience, and the second to assess behavioral traits.
Before offering a position, be sure to check state regulations regarding medical professionals and approved responsibilities. “M.A.s might be able to take x-rays under the auspices of a doctor in one state. In another they can give injections, but in a different state only a licensed practitioner can do this.”
Investing significant time in the hiring process will help identify the most qualified candidate, but Dr. Braddock said it is important to consider the candidate’s personality too. “There is a one-on-one relationship in which you have to trust the doctor. [Physicians] have to have the personality to deal with people and patients, [to] be open and honest.”
TRAINED STAFF
From their first day, a new staff member needs to be oriented to the clinic’s expectations, which should be defined during the job interview. But every program differs, so it can be challenging to understand services like audiograms, respiratory clearances, worker’s compensation, and OSHA 11 regulations. “There is a lot of on-the-job training. Programs need about six months to know if the person they hired is appropriate,” Dr. Anderson said.
Unfortunately, there is no training program specifically for occupational medicine. “It’s helpful overtime to send more tenured staff to various specialized trainings, such as Hearing Conservation Training,”
said Dr. Anderson, because it is important for the employee to know why she is administering such a test. “When staff understands the testing and genesis, it makes more sense.”
A team in which everyone knows and understands their individual role will form a well-run practice, but cross-training can make a smooth operation run even better. “As a backup, employees should know how to do one another’s jobs, within the realm of reasonableness. Everyone should be trained in CPR and basic first aid and know when to call 911,” said Ms. Gardner. “No one is too high up to not do a certain job.
The goal is patient and client company satisfaction in a timely manner. How professional and well-trained your staff is will be reflected in patient satisfaction surveys.”
RETENTION
In spite of the most thorough interviews and seeming compatibility, sometimes staff members leave. The cost of interim help, plus recruiting and training someone new, can have a huge financial impact.
According to The Center for American Progress, replacing an employee costs a business approximately one-fifth of their salary. Moreover, for jobs involving high levels of education and training, the cost might
be as high as 213 percent of their salary. (Read the study here, https://www.americanprogress.org/article/there-are-significant-business-costs-to-replacing-employees/.)
But holding regular retreats can foster a friendly and cooperative work environment, Dr. Braddock said. Full-day or weekend-long encounter groups with team-building events help staff members bond while working toward a common goal. “If you don’t provide an enjoyable environment, you won’t have cohesion. You become silos, insular to others around you,” he said.
Trena Williams, R.N., C.O.H.N., director of clinical services at Spartanburg Regional Healthcare System in Greer, South Carolina, suggested creating action plans for retention based on employee surveys. “The responses from those surveys will give you an idea of what to
focus on.”
Ms. Williams’ program recently implemented the Studer principles (www.studergroup.com) which focus on excellence, “taking a system from good to great,” she said. For instance, she sends thank you notes to staff upon peer recommendations. “We’ve only been doing this for a month, but it’s had positive results.”
Communication plays a huge role at Spartanburg Regional as well. The facility publishes a regular newsletter and schedules personal meetings with staff members every month to gauge job satisfaction. “We also have a communication board for employees that presents quality indicators, results of client surveys, information about community events, and other relevant topics,” Ms. Williams said.
At the end of the day, an occupational medicine program is only as good as its workers. Patient flow, patient care, patient satisfaction, and, ultimately, the future of your program rest squarely on the shoulders of your staff.
