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LearnIng objectIves

C H A P T E R 8


They’re not employees, they’re people.

—Peter Drucker

➤ Describe the range of human resource functions in the medical practice.

➤ Appreciate the range of professionals that are found in medical practices.

➤ Articulate the steps in the hiring function.

➤ Understand regulations that are specific to the employment process.

➤ Illustrate the steps in managing change.

➤ Describe why leading change is important to medical practice management.

IntroductIon Healthcare employment constitutes about 9 percent of the American workforce, with about 3 percent being professionals (KFF 2016). Hiring and sustaining a high-caliber staff are two of the most important functions of managing a physician practice. Without a prop- erly trained and motivated staff, providing high-quality services to the practice’s patients

C o p y r i g h t 2 0 1 7 . H e a l t h A d m i n i s t r a t i o n P r e s s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

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is difficult. An old saying in human resources management, “Hire for attitude, and train for skill,” is particularly applicable today, when in the highly competitive medical practice environment, patients have increasingly high expectations of their providers. Simply having technical skills is not adequate to build and maintain a successful practice. Staff must be able to engage patients in a positive and constructive way to earn their trust and satisfac- tion. Although data seem to conflict on this point, many researchers believe engaged and satisfied patients are more likely to comply with the instructions of their providers than are disengaged, unsatisfied patients, leading to better outcomes (e.g., Kane, Maciejewski, and Finch 1997). More recently, a study by Fenton, Jerant, and Bertaski (2012) found little connection between satisfaction and clinical outcome; in fact, the researchers found that mortality was higher, as were expenditures and utilization, among more satisfied groups. Other authors have observed this tenuous connection as well (Kennedy, Tevis, and Kent 2014). The controversy has intensified as more physician payment is tied to patient satis- faction. Some issues that complicate this concept are the lack of common definitions and measures of satisfaction and the complexity inherent in defining what produces satisfaction, which goes far beyond the clinical or office experience (Berkowitz 2016). Regardless of the evidence, satisfying and engaging patients is a desirable goal for any practice if for no other reason than it creates a pleasing practice atmosphere.

the PeoPLe In the PractIce A number of terms are used to describe medical practice employees in general, some of which are often used synonymously. They include teammate, associate, colleague, and staff member.

Furthermore, a variety of terms are used to describe the physicians and providers of the medical practice, with medical staff a common phrase. Interestingly, physicians often refer to each other as partner, even when the practice is not an actual legal partnership. The term partner in this sense denotes the collegial relationship among the physicians of the practice.

Practices may also employ many different nonphysician professionals. Exhibit 8.1 lists some of the numerous nonphysician practitioners who may be found in the medical practice.

The number and type of nonphysician practitioners vary dramatically from practice to practice, depending on size, specialties, and services provided by the practice. Small, single-specialty practices may have few on staff, whereas large, multispecialty practices likely employ several types of nonphysician practitioners.

the emPLoyment, recruItIng, and hIrIng Process Hiring new staff requires careful planning and preparation. Depending on the size and complexity of the practice, recruiting may be the responsibility of the practice manager;

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in large practices, that task likely is performed by a human resources department or hiring manager. The process should be similar to that described in this section regardless of who undertakes the endeavor. Physician recruiting may differ somewhat, and practice providers inevitably are involved in their hiring, whereas they may not be involved in nonphysician staffing. Often, physicians want to be involved in recruiting the members of the practice who will work directly with them.

Next, we discuss nine steps in the employment process, from identifying staffing needs to conducting interviews.

Nurse Pharmacist Physician assistant

Nurse practitioner Allied health professional Anesthesia technician

Art therapist/art psychotherapist

Athletic trainer Audiologist

Cardiovascular technologist

Clinical laboratory scientist Medical coder

Diagnostic sonographer Dietitian/nutritionist Electrocardiogram technician

Emergency medical technician

Environmental health officer

Exercise physiologist

Kinesiotherapist Massage therapist Medical assistant

Medical interpreter Medical laboratory scientist

Medical radiation scientist

Music therapist Neurophysiologist Occupational therapist

Paramedic Perfusionist Phlebotomist

Practice manager Public health epidemiologist

Physical therapist/ physiotherapist

Radiotherapist/ radiation therapist/ medical dosimetrist

Diagnostic radiographer Recreational therapist

Rehabilitation counselor Renal dialysis technologist Respiratory therapist

Social worker Speech and language pathologist

Surgical technologist

exhIbIt 8.1 Nonphysician Practitioners Often Found in the Medical Practice

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steP 1. IdentIfy needs

Before any action is taken, the practice must determine its specific needs regarding a poten- tial new employee. This step is especially important if the position is new and not simply a replacement for a departing member of the practice. Often, this determination is made through the use of a quality improvement process, which may help to determine how the position might change or whether the position continues to be necessary.

At the same time the job needs are being identified, the practice should be clear as to who will be responsible for overseeing the steps of the hiring process and who will conduct each step. Recruiting is a multistep process, and accountability for each step needs to be defined to ensure that no missteps or misunderstandings occur.

steP 2. deveLoP a PosItIon descrIPtIon

The position or job description is an essential document, for the hiring process and beyond, that articulates the responsibilities and requirements of the job and identifies tasks and accountabilities. In addition to recruiting a new member of the practice, the job description may serve as key evidence in any defense against discrimination claims in hiring should they arise.

Job descriptions should focus on the requirements of the job and the skills and education needed to fulfill the position’s duties. Importantly, it should leave as little of the decision making to discretion as possible, as this could introduce bias. Therefore, the job description should be carefully worded to reduce the possibility of misunderstanding among all parties involved in hiring for the position.

The position description should contain information about the essential functions of the job, the purpose of the job, minimum requirements, and preferred requirements. Distinguishing between minimum and preferred requirements is important to assure appli- cants that only those individuals with the minimum requirements will be considered for the job. Targeted, specific language contained in the job description also improves search engine optimization when attracting candidates.

Beyond the hiring process for a candidate, the job description can be a valuable tool in career planning and training. Some practice employees may aspire to other jobs in the practice, and the job description for those positions helps the practice manager or human resources staff member guide the teammate in understanding the training and experience needed to achieve his or her goals. It is a blueprint for building one’s career.

steP 3. deveLoP a recruItIng PLan

Once the job description has been created or updated, a recruiting plan for the position needs to be developed, which includes the following:

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◆ Where will the job be posted to attract candidates? Recruiters have many options: Internet job boards, advertisements through professional societies, ads in local and national publications, word of mouth, and direct contact with training programs are a few. Asking current employees to refer qualified candidates is also an attractive option.

◆ How long will the posting appear? Although no specific standard is recommended for the optimal duration of a posting, it should be long enough to receive an adequate number of qualified candidates. In many cases, the position is posted until filled.

◆ How will resumes and applications be managed? In medical practices, this is an important consideration. Depending on the size and complexity of the practice, the practice manager or members of the practice dedicated to human resources management may be the primary people responsible for recruiting. In other cases, multiple individuals (e.g., a committee) may be involved if many stakeholders have a vested interest in the recruiting process. Hiring a new practice manager or administrator might be an activity for which a committee should be formed. In the case of hiring clinical staff, the physicians may wish to be involved, especially when, as noted earlier, the person being hired will work directly with them.

In some cases, the practice may use an outside recruiting agency if the internal capabilities of the practice are limited in the human resources area.

steP 4. ImPLement the recruItIng PLan

During this step, the practice posts the position opening on job boards, career sites, and organizational job boards selected for appropriateness and reach to desired candidates. For example, the American College of Healthcare Executives and the Medical Group Manage- ment Association host extensive online job boards that are visited frequently by members of these organizations and are an excellent target audience for several practice positions. In some cases, newspapers and professional journals may be appropriate places for advertising the open position.

steP 5. receIve and revIew aPPLIcatIons

During this step, candidate applications should be compared against the criteria estab- lished in the job description. A spreadsheet or another tool that allows the recruiter to list the applicant’s name followed by the job criteria he or she meets—or fails to

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meet—can be helpful in narrowing down the choices to the most qualified candidates for further review.

steP 6. conduct IntervIews

The interview process may be divided into two phases. The first phase typically involves a telephone or Internet-based voice (e.g., Skype) interview with candidates who appear to meet the criteria established for the position. This phase is useful when several candidates meet the minimum qualifications or when some of the candidates would have to travel a long distance for a face-to-face interview. After this initial round of interviews is completed, face-to-face interviews with the top candidates are conducted.

Interviewing is an important skill set that should be developed by the members of the practice engaged in hiring. The sophistication of the interview is largely determined by the background and experience of the interviewer and the amount of recruiting the organization has performed (the main reason some organizations use recruiters).

Interviews can be undertaken by the recruiter along a spectrum of difficulty. Some interview approaches are considered light on substance or easy for the interviewee to perform well in, called softball interviews. On the surface, this tactic might sound appealing, but it is not recommended. The number one reason new members fail at a job is that they prove to be a poor fit with the organization. A rigorous but respectful and fair interview process helps to ensure a good fit. Few people set out to do a bad job in a new position; to help them succeed, the recruiter should articulate during the interview what is expected in the role and how the candidate’s qualifications match up to these expectations.

A rigorous interview process does not involve treating candidates rudely or disre- spectfully. The interview is likely the first opportunity the practice has to demonstrate to prospective employees or medical staff how it treats its employees, and it reflects on you as a manager.

Recruiting is a high-stakes undertaking for the practice to ensure that the “right” person is hired. One suggestion for gaining insight on how interviewees will fit with the practice is to watch how candidates interact with others. Are they courteous to everyone? Do they say hello to the receptionist and the housekeeping staff or any other practice members they meet? Do they smile? These are clues to the emotional intel- ligence (EQ) of the applicant. (EQ is discussed in more detail later in the chapter.) Applicants are likely on their best behavior, so negative signs about their interactions with other people may be an important indicator of future performance with patients and other employees.

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Possible Candidate Interview Questions

A key aspect of effective interviewing is to have a prescribed process in place that is applied consistently so all candidates are posed questions that are similar in scope and specifics. Prescribed interviewing allows for a fair evaluation of candidates.

Interview questions vary significantly depending on the nature of the position and the skills required, but some recommended general questions to ask are as follows:

◆ Tell me about yourself.

◆ What are some of your personal and professional achievements?

◆ What are the critical factors for a satisfying practice for you?

◆ What factors will have the largest impact on your decision as to whether to join us?

The following additional questions can elicit insight on a candidate’s strengths, weaknesses, and leadership abilities:

◆ Tell me about your interpersonal style.

◆ How do you get along with others?

◆ Do you like working as part of a team?

◆ How do you manage conflict?

◆ Tell me about a time you had to deal with a difficult situation with a colleague, someone you reported to, and someone who reported to you.

◆ What type of people do you have trouble working with?

◆ What type of patients do you have trouble dealing with? (This question is often specified on the basis of specialty.)

◆ How do you respond when you have problems with someone?

◆ What have you heard about our practice or organization that you have questions about or don’t like?

◆ What interests you most about our practice/organization?

◆ Where do you see yourself in five to ten years?

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◆ Why should I hire you?

◆ What kinds of situations or occurrences make you angry?

◆ How well do you work under pressure?

◆ Do you consider yourself a flexible person?

◆ What motivates you?

Questions You Should Never Ask

Personal questions that could form a basis for discrimination, such as questions about race, ethnicity, age, gender, sexual orientation, or marital status, should never be asked. Even questions about how the person will get to work can be interpreted as discriminatory and may lead to legal action if that person is not hired. The practice has a right to require staff to arrive on time for their scheduled shift, but how they get there is not the practice’s concern. The best—and only—questions to ask are those that relate to the job and to the person’s ability to perform the job functions.

Questions the Applicant Might Ask

Asking the applicant if she or he has any questions is an accepted and appropriate aspect of the interviewing process. Following are some common questions that may be asked by the applicant:

◆ What is the scope of the practice?

◆ What qualifications are you looking for in a candidate?

◆ Tell me about a typical workday or workweek.

◆ Why is the practice recruiting?

◆ What are the plans for the practice?

◆ Can you tell me more about the practice’s community involvement?

◆ What hospital(s) does the practice use?

◆ Can I meet other members of my department?

◆ Does the practice plan to offer any new services in the near future?

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steP 7. decIde whIch aPPLIcant to hIre, and make the job offer

The decision to hire an applicant may be made in a number of ways. In some organiza- tions, the hiring manager or practice leader meets with practice members with whom the candidates will be working to hear their impressions of the candidates. Depending on the nature of the job and the size of the practice, physicians and other staff may also be involved. It is always a good idea to involve as many people as possible who will be in contact with the new hire. This is especially true of the smaller practice, since everyone will likely work in closer proximity to one another.

Making the job offer usually begins by contacting the successful applicant by tele- phone and offering him or her the job. Any verbal offers must be followed up with an offer letter that specifies the salary and benefits being offered, as well as other important details, such as the employment start date. The letter should also state that the offer is subject to the findings of a prehire health screening and background check (see step 8) and should request acknowledgment of the offer with the candidate’s signature indicating formal acceptance of the job.

steP 8. conduct PrehIre heaLth screenIng and background check

Medical practices engage in some of the most important human interactions people experi- ence in life, and this role underscores the need for practices to employ dependable, honest teammates. One recommended hiring practice is to conduct a prehire health screening for drug use and a criminal background check for all new employees. Using a professional agency for screenings is advisable for smaller practices because of the special and sensitive nature of this task; the practice must avoid mistakes that could cause legal repercussions or the loss of a great employee.

steP 9. weLcome and onboard the new emPLoyee

The practice should develop a thorough onboarding process for all new members. It should include activities as mundane as the location of their workspace, restrooms, and break facilities to those as specific as a detailed review and training regarding the specific job. See exhibit 8.2 for a sample onboarding checklist.

taLent management Managing the human resources of the medical practice requires attention to a number of important elements, including performance management, compensation and benefits, and development of each person’s potential.

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