How Many Staff Do You Need in a Medical Practice?

Staffing your office can be a daily balancing act.

The Receptionist

There’s no simple formula that one can apply to every practice because each specialty and each situation requires something different. It is very important to right-size your staffing as understaffing can cause patient dissatisfaction, frustration, burnout and a staff exodus. Overstaffing can cause lower productivity, reduction in profit and never really getting to the root of why some problems exist.

Matching FTE Providers to FTE Employees

Most benchmarks utilize FTEs, or full-time equivalents which is an employee working a 40-hour week, or a provider working the number of hours considered full-time for providers. Although this works well for employees, it doesn’t always follow for providers. A .5 FTE provider that works two days a week may need more than a .5 clinical and .5 non-clinical person because patients still call for prescription refills and questions and test results still arrive to be reviewed on the days the provider is not there.

Back to basics

It helps to bring the equation down to the simplest formula of clinical and non-clinical staff. For now, disregard billing, lab, other ancillary services, management, and medical records and focus first on the number of staff needed to get the patient in the door (front desk), get the patient seen (clinic assistants), and get the patient out the door (front desk again.)

Let’s imagine that Dr. Goodman is a full-time primary care physician. He works 4.5 days per week and has one non-clinical person who answers the phones, checks patients in, checks patients out and handles the medical records. He also has a clinical person who rooms the patient, performs the intake, and takes the vitals. The clinical person also answers patient phone calls with medical questions and contacts patients to give them their test results. Either employee may schedule tests and referrals for patients.

Dr. Goodman has 2 full-time employees and if he’s really fortunate, both employees are interchangeable so each can fill in for the other if they want to take vacation or are sick for more than a few days, maybe with the help of a temp or a friend if needed.  If the practice also has electronic medical records (EMR) and everything is as automated as possible, they can probably get by just fine for short periods of time.

Now, consider an office with ancillaries or with more providers:

  • Front desk – as the number of providers grows, so does the need for more staff to check patients in or check patients out. Floating staff between these positions can be a temporary solution before adding full-time staff in both areas. Using a patient check-in kiosk can minimize the stress of checking-in many patients arriving simultaneously.
  • Dedicated phone staff – when employees are pulled between answering the phone and working with the patient in front of them, it’s time to consider a separate phone position away from the front desk.
  • Nurse triage – if providers are seeing patients all day, every day, clinical assistants may not have the capacity to answer phone calls between patients. Nurse triage can also keep the office flow even by deciding when patients need to come in for same day visits. Nurse triage is more common in primary care.
  • Laboratory – services could be as limited as the clinical person taking specimens, or as complex as a full-blown lab staffed with a full-time lab tech to draw blood and test it.
  • Referrals – most primary care offices refer patients for lots of tests and if the process is not electronic and requires lots of time on the phone, you may need to dedicate a FTE person to this job if you have 3-4 providers.
  • Billing – billing can be completely outsourced from the entering of charges to pushing accounts to collections, or it can be handled in-house. A typical ratio is one billing person to two providers.
  • X-ray – for those offices that require x-ray, one employee is enough only if there is another x-ray facility close by.
  • Medical records – depends entirely on the office flow, the size of the office (how many places can a medical record hide?) and how many records are flowing in and out of the office every day.
  • Transcription – unless the provider hand-writes office notes or is using voice recognition, transcription will need to be provided for in-house or be out-sourced.
  • Management – when does a practice need a manager? Well, that’s another post for another day, but typically a solo physician does not need a manager, unless he has lots of ancillaries with lots of associated employees.

And in a specialist’s office:

  • Surgery scheduling – in some surgical practices, the clinical assistant does the scheduling while the physician is in surgery. Larger practices employ centralized surgery scheduling which usually takes  2 schedulers to make sure one scheduler is available at all times.
  • Specialized Testing – one technician is usually enough for each testing modality, unless the practice is doing testing for other practices. The other exception is if the equipment, a nuclear camera for instance, is so expensive that the practice cannot afford to not be able to do tests if an employee is absent.

Why do some offices need more staff and some need less?

  • Inefficiency requires more people! If people have to get out of their seats to solve a problem or get an answer, they’re inefficient.
  • Systems and processes must support the work of the employees.
  • Some physicians can keep two (or more) clinical assistants busy.
  • Some physician specialties order many more tests and need more staff to schedule them.
  • More people are required to manage paper charts than are needed for electronic medical records.
  • Healthcare requires more paperwork and more phone calls than it did even 5 years ago, and it takes more people to handle the paperwork and the calls.

What should you do if you can’t figure out if it’s taking too many people to do the work?

  1. Make sure you know exactly what every person is doing. Have everyone keep a log of all the jobs they do over the course of several weeks. Ask them to assign the percentage of time they spend doing each task. Evaluate their lists and see if staff are carrying equivalent workloads.
  2. Make sure you cross-train employees and see if jobs take more or less time when others do the tasks.
  3. Is every task something that contributes to the practice? Does something absolutely need to be kept in two places in two formats? Are things being done because “we’ve always done them that way?”
  4. Is one thing so far behind that it’s causing duplication of effort? Bring in a temp,  ask staff to work on a Saturday, do whatever it takes to bring everyone back to ground zero again.
  5. Hold brainstorming sessions with staff and involve them in developing plans for improving efficiency. Also ask them one-on-one for their ideas for improvements.
  6. We do expect more of everyone than we did before the economy tanked, and employees are responding by being more stressed and by being out sick more. Evaluate if everyone is out more than in the past and how that may be affecting the work.
  7. Do a simple efficiency study by observing individual employees at work and documenting what they’re doing one minute at a time for a period of two hours. Graph the work by time to see what two hours of their day looks like. Some jobs are by nature “interruptable”, like phones, check-in and check-out, and some jobs are performed best when the employees are subjected to minimal interruption. Are these jobs defined in this way, or are the two interspersed creating inefficiencies?
  8. Try this exercise: create the ideal staff for your office as if you could afford every person you’d like to have. Then, start to work backwards, seeing how jobs could be combined and what positions would be nice, but not necessary. Compare the final product to what you have now, and see what the differences are. Another way to approach this is to pretend your practice doesn’t have the physical confines that it does, and see if you would staff it differently if the space was more accommodating.

Photo credit: Image by mpujals via Flickr

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Posted in: Day-to-Day Operations, Electronic Medical Records, Finance, Human Resources

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24 Comments

  1. Mary Jean George June 6, 2011

    I really enjoyed your articles! I in the process of opening HR-PRN, LLC consulting services for small medical practices managed by an office manager or a spouse that has little or no access to Human Resources knowledge or consultants. I have over 30 years of Human Resources experience and I know that small practices struggle when it comes to the basics of Human Resources management. I look forward to more of your informative articles.

  2. Mary Pat Whaley June 6, 2011

    Hi Mary Jean,

    Congratulations on your new venture and best of luck!

    Mary Pat

  3. Laura Fairclough June 8, 2011

    I found this post very helpful. I am employed in a medical practice with five providers and the clinical and non clinical staff always seem to be stressed and overloaded. This gave me some insight to some of our problems.

    Thanks.

  4. Mary Pat Whaley June 10, 2011

    I’m so glad you found it helpful!

    Best wishes,

    Mary Pat

  5. Judy July 10, 2011

    We are 5 months into an outpatient clinic. As an RN I am quite comfortable with the clinical side, but am struggling with the “office” side and patient/paper flow even though we have EMR. I appreciate your information as I ponder where to make changes. Although we need more staff due to increased patient volume, right now it would only add to the chaos :)

  6. Mary Pat Whaley July 11, 2011

    Hi Judy,

    What most practices need is a management system for all the other paper records, just as you have the EMR for all the documents related to patient care. Most practices create, send and receive an incredible amount of paper daily and stuffing it all into a filing cabinet is largely unhelpful. Almost all paper in the practice needs to be shared by a number of people either for information or for collaboration. This problem is the reason I went looking for a document management system that does more than just store documents. What I found was Box as a foundation, and I developed an application to make it fit the way medical practices work.

    On the other hand, I’ve also developed some great low-tech manual systems to help with paper and information flow around the office. If you want to write to me at marypat@managemypractice.com and tell me exactly what your problems are, I’d be glad to help you however I can.

    Best wishes,

    Mary Pat

  7. Patti Murrietta October 17, 2011

    Hello, Well our office has one very busy Gastroenterologist and one busy General Surgeon. We do not have EMR yet, but we are looking into it. We have only 4 full time people and 2 part time. We do all the billing also for both of these doctors. My GI doctor does well over 30 procedures a week. We do all insurance auth and surgery schd..plus all the dictation printing and filing..We are extremely busy at all times. What would be the correct number of staff for a two specialty office?? We split their office time so we don’t have them both here on the same day, but there are days when we do… Yes, we are crazy, but we all work very hard and care about the job we do for them.

    1 FT office manager / 1 FT Biller 1 PT biller / 1 FT medical Assistant / 1 FT surgery schd/ins verifier / 1 PT receptionist ( we all cover each other )

    I just want to explain to the doctors, that even if their not here there is still plenty of work to do. What would a “normal” office have as far as staff.

    Thank you!! Patti

  8. Mary Pat Whaley October 19, 2011

    Hi Patti,

    Every office is different, so I could guess at how many people are needed, but until I came to your practice and saw for myself who does what and what, if anything, is not getting done, it’s hard to say you have too few or too many staff.

    Here are the questions that will give you the answer:
    – is there anything that is critical that is not getting done?
    - do you hear complaints from patients about anything in the practice?
    - are your key indicators in line – days in A/R, no-show rate, collection percentage, new patient numbers?
    - are staff burned out and showing signs of stress?

    Are your docs complaining about the number of staff? Doctors often point to payroll as the expense that has increased the most over the years and the one that should be trimmed to save money, but hopefully most understand that staffing can make or break their practice.

    Best wishes!

    Mary Pat

  9. Jason November 29, 2011

    Dear Pat,

    I have recently started in the medical field, I am working for a pain management office in Indiana. The doctor just recently started in office procidures (epidurals,facet blocks, ect…)in two locations. One doctor owns and practices in both locations. I have worked in both locations doing what I guess is administration duties. The doctors wife acts as both office manager and patient advocate. I have been with them for two years, we have gone from 127 patients at my base office to 667 patients, the other office has grown almost as much. The doctor travels, 3 days at our office(tues., wends.and sundays), then Mon., Thur. and Fri.at other office. I am overwhelmed we have 3 staff members in each office. Is this normal, how can I convience we need help. HELP!!!!

  10. Mary Pat Whaley December 4, 2011

    Hi Jason,

    You don’t really say what each of the 3 people do, or what you need help with. Feel free to write to me at marypat@managemypractice.com with more details.

    Best wishes,

    Mary Pat

  11. Carol February 8, 2012

    Our office is merging with another specialty office and we will have 3 providers 2 of which will be surgeons and 1 physician assistant. Although the 2 surgeons will alternate days in clinic due to surgery days we will all be in clinic at least 1 to 2 days a week. How many staff members do you think will be adequate to run a smoothe functioning office Monday thru Friday 8 am to 5pm.

  12. Mary Pat Whaley February 12, 2012

    Hi Carol,

    Much will depend on which specialty you are and how the duties are split among the staff. Different specialties will have different levels of office needs based on the physician’s activity – procedures, diagnostics, etc. I would need to know how heavy your phone volume for clinical questions is, as that also will vary by specialty. Each surgeon and the PA (if s/he has their own schedule) will need one assistant for clinic days, and you potentially may need a phone nurse if you have post-op patients calling with questions that should be answered rather quickly. On the days that all providers are in the office, that means 4 clinical assistants (MAs, RNs, etc.) On the days that one or more providers are in surgery, one of the assistants can be the phone nurse, or two can each take the phones 1/2 a day, leaving the rest of the day for other duties. Clinical assistant duties may vary based on who is assigned to perform tasks such as surgery authorization, surgery scheduling, surgery packets, pre-op reminder calls, post-op patient calls, etc.

    As far as non-clinical staff, I would expect you would need two front desk staff (check-in and check-out) and depending on how much testing is referred out, you may also need a referral clerk or the clinical assistants may schedule tests. You would need a backup for the front desk, which could be one of the clinical staff or could be the manager, and depending on whether you are using paper or electronic charts, you may need a medical records person. Your billing should be able to be handled by one person, especially if you are leveraging technology and if the front desk is posting the charges and over-the-counter payments.

    My best guess:
    2 front desk (possibly a 3rd for medical records if paper)
    3 clinical assistants (possibly a 4th 2 days a week for phones)
    1 billing
    1 manager

    Best wishes,

    Mary Pat

  13. Tammy Hines February 25, 2012

    We have a very busy medical office. We only have 2 employees. We do have EMR. The “acting” medical assistant scans all documents to our EMR. I answer phones, make appts, check pts out, do all referrals, scheduling tests etc. I also have to put in all documentation into emrs. All ICD and CPT, testing ordered, charges, refills etc. Sometimes we are just so overwhelmed we cannot see straight. Up until 3 years ago we had a 3rd person but now he is not wanting to pay a 3rd person. Is he wrong or am i just getting to old to keep up?

  14. Mary Pat Whaley February 27, 2012

    Hi Tammy,

    I wish I knew what specialty your practice is as that can make a significant difference. You don’t mention any billing – is that outsourced?

    It sounds like the office is incredibly busy, which is good, but if you are overwhelmed more than 1/2 of the days that the practice is open, something is probably going to give sooner or later. What in the world do you do when someone takes a vacation?

    I wonder if any improved workflows could bring efficiencies to your practice and relieve some of the pressure. Also, maybe your doc would be willing to bring someone in for 3 hours a day – that might make all the difference in the world and could be very affordable.

    I don’t think you’re too old to keep up, but healthcare today is a lot different than it used to be. It’s a well-worn cliche, but we must work smarter and not harder. We have to develop better workflows, leverage technology and be constantly trying new ways to do things.

    Best wishes,

    Mary Pat

  15. Tammy Hines March 4, 2012

    It is internal medicine/family practice. As for vacations we will be finding out real soon, my coworker is getting ready to go on maternity leave. He is just expecting me to do both jobs, he does bring in his wife who can check a pt. in and weigh them and that is about it. She will answer the phone and hand it off to me because she doesn’t know what to do. I am just at a loss as to what i am going to do when this baby comes. Our EMR company does do our billing otherwise i think we would of crashed and burned by now. That 3rd person for a few hours a day and to cover for vacations would be great but i just don’t see that happening. Thanks for making me feel like i am just not losing it!

  16. Mary Pat Whaley March 4, 2012

    Hi Tammy,

    I think most of us feel like we are losing it at one time or another!

    Hang in there.

    Best wishes,

    Mary Pat

  17. Carol Cohen August 6, 2012

    I have a small 3 person office with 4 PT MDs. Once I subtract vacation hours, estimated sick hours from each 2080 hour person, it is no longer 2080 hours. How do i figure out how many full time people i’m really utilizing?

  18. Mary Pat Whaley August 7, 2012

    Hi Carol,

    When I work on staffing models, I consider staff to be productive 6.5 hours per day. The remainder of the day is taken up by breaks and also accounts for paid time off. So, when I am looking at the job to be done, although I am hiring an 8 hour per day person, I should only allocate 6.5 hours of productivity. To answer your question, if you have one front desk/check-in position, you know that 1 FTE will not be enough to cover that position as one person will take vacation, get sick, be called to jury duty, etc. Who will cover? Will it be another staff person who can be pulled to cover? Will it be someone who floats to different positions based on the need on any given day? Will it be a prn person who is glad to work a week or two and make a little extra money? All of those answers are possible staffing models you can experiment with.

    I always staff to a little above average, in other words, I don’t staff too lean because employees get burned out and use more sick time (unscheduled absences) and sometimes quit. I don’t staff too cushy because it’s not affordable. I staff a little cushy to keep good staff, but a little lean to keep payroll at an acceptable level.

    Best wishes,

    Mary Pat

  19. Kim Davis April 26, 2014

    Hi,
    I have been the only full-cycle Medical Biller for the past 18 months. Previously, there was another part time biller and a FT patient account rep. There are 10 FT Physical Therapist’s plus a few PTA’s and 2 Massage Therapist. We do about 3500 visits per month. During the last year, we went through a complete software and clearinghouse transition and now have EMR- which is great- but I have a crash course on the new system with nobody to go behind me on anything that went sideways. I have been working out of the old system and the new system. I am completely burned out/trashed. I have talked to the owner and the CEO about getting more help and reminding them that to have a successful company they also need a properly staffed billing dept. They recently brought on a payment poster to post all paper deposits, which does not include the electronic deposits…and that’s it. Honestly, I feel like I’m losing my mind and am absolutely exhausted. Can you tell me if I am really losing my mind or are they extremely understaffed in the billing dept? The money is coming in but I will give God that credit. Help, I need it!

  20. Mary Pat Whaley May 5, 2014

    Hi Kim,

    From what you describe it does sound like your “department” is seriously understaffed. Depending on the specialty and how much support technology you have, with an efficient, streamlined system a single biller can handle between 500 and 1000 visits per month. At the low end, you would need 3.5 billers.

    I hope this helps.

    Best wishes,

    Mary Pat

  21. Vicki Spencer June 20, 2014

    I’m an RN in a multi-spec. office, working for 3 FT surgeons. We have 1 MD in clinic every day. My question is how many clinical staff are required?

  22. Mary Pat Whaley July 16, 2014

    Hi Vicki,

    It depends on how many patients are seen in the office on that day, what the duties of the RN are and what the specialty is. Some surgeons do more in the office than others and it takes more clinical help. Some surgeons really pile up the schedule and it takes two assistants to keep the office flowing well. If the RN is doing the surgery scheduling or any other work associated with the surgery process, there might not be enough time to assist the surgeon and get the paperwork done. It all depends on the surgeon and the way the office work is divided.

    Best wishes,

    Mary Pat

  23. Sarah July 21, 2014

    Our office is a multidisciplinary PM&R practice. One of our FT MD’s performs procedures in office (epidural’s, RF’s SCS Trial’s etc.) He also see’s a few new patients and follow up’s. Maybe 5-10 per week. He is in office 4-5 days a week. We generally schedule 20-30 patients per day. Currently, we have 3 MA’s assigned to him. They are responsible for taking patients back for intake, working in the procedure room, recovering the patients as well as scheduling their next appointment while the patient is recovering. They also make some patient call’s for follow up, as well as call for testing as needed. The Dr. travels to other clinics so the staff generally do the admin type duties on the days he is out of the office as well as one – two staff travel with him to the other clinic. We do have 2 FT front desk staff who check his patients in as well as the other providers in the office. They are also responsible for this particular Dr.’s scheduling needs. We feel we are adequately staffed with 3 FT MA’s for 1 FT MD. Staff feel they are understaffed. Do you have any advice? Thank you!

  24. Mary Pat Whaley July 23, 2014

    Hi Sarah,

    I would have the three MAs document their tasks by time for several days and/or shadow them one at a time to see why they think they are understaffed. I have certainly seen one or two doctors that could keep 2-3 MAs busy, but usually only during clinic hours. Having the staff document their tasks by time (yes, it will take even more time to document their movements) is one of the few ways you can get to the bottom of what they are doing to keep 3 of them busy all the time every day. Shadowing them, which is even more resource-intensive as it will take one FTE’s time for at least 3 full days, will be even more illuminating. Staff can write down what they’re doing all day, but having a third-party write it down will be much more objective. You might even get some process-improvement ideas in the bargain.

    Best wishes,

    Mary Pat

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