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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Six Reasons Why Your Doctor’s Office Doesn’t Call You Back and a Few Solutions

A patient having his blood pressure taken by a...

Patients want to know why they can’t get a return call from their doctor’s office – here are six reasons why the calls have increased and physician offices are having trouble meeting the needs of their patients.

  1. Medication questions and requests for a prescriptions change. The average number of retail prescriptions per capita increased from 10.1 in 1999 to 12.6 in 2009. (Kaiser Family Foundation calculations using data from IMS Health, http://www.imshealth.com.) Because it is not easy to access prescription cost by payer in the exam room, medical practices get lots of callbacks from patients asking to change their prescriptions once they arrive at the pharmacy and find out how much the prescription costs.  Related issue: Many national-chain pharmacies have electronic systems that automatically request a new prescription when the patient is out of refills.  Also related: Patients calling to ask for additional medication samples.
  2. Patients are delaying coming to the physician’s office by calling the practice with questions. Patients want to forestall paying their co-pay or their high-deductible by getting their care questions answered without coming to the doctor’s office.
  3. Patients call back with questions about what they heard or didn’t hear in the exam room. They may not remember what the physician told them, they may not have understood the medical jargon, or they may have a hearing problem and were not comfortable asking the physician to repeat something.
  4. Impatience: we live in an instant gratification world and patient expectations are not aligned with what physician offices can realistically provide.
  5. Some patients will not leave voice mail messages and will call back multiple times until they get a live human being or will punch in options until they find someone to answer the phone.
  6. Physician offices are often understaffed. Physicians find it untenable to add more staff to do more tasks for less money or no money at all.

And here are some possible solutions:

  1. Have formularies for all major health plans on hand in the exam room. These could be paper lists, or electronic lists for the tablet or smartphone. (Note: Epocrates currently has a deal with Walgreen’s to support their discount program on the smartphone.) Don’t underestimate the patient satisfaction and reduction in callbacks for sending the patient out of the exam room with the right prescription.  Automatic refills are not an appropriate function of pharmacies.  Physicians should provide samples (check the formulary!) and a prescription to get filled if the samples do the job.  If a patient can’t afford the brand name prescription, a prescription assistance program is the next step.
  2. Patients need to be advised appropriately when they need to see the physician and when they don’t. Good triage nurses can be worth their weight in gold, but you can hold the costs down by hiring a triage nurse or several to work from their homes taking calls from your patients.  The nurse will need to have access to your practice management system to schedule appointments and to document the conversation if the patient is given advice.
  3. Provide patients with different modes of assimilating health information. Some patients are recording office visits via voice or video and one of the goals of meaningful use is providing patients with an office visit summary when they exit the practice. Websites should be loaded with educational information that physicians can “prescribe” to their patients. Some physicians help to cut down on return calls and improve understanding by asking the patient how they’ll describe the visit to a family member.
  4. Give patients (on the web, in the practice, on your on-hold messages) realistic timelines for callbacks and make it so.
  5. Yes, some patients will game the system to get their needs met ahead of others. Ask them to adhere to the practice guidelines. There will always be some cheaters, but most patients will respect you if you respond to them when you said you would.
  6. The only answer to understaffing is technology. Use a patient portal to allow patients to request refills, schedule appointments and chat with billing staff or nurses. Replace paper charts with EMR. Use efaxing to eliminate paper faxes. Use the cloud to store information and collaborate.

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