Manage My Practice

I don’t often find articles that reflect my own views as closely as the article “10 Ways to Keep Employees Happy” from HowStuffWorks by Cristen Conger does. Not only does Ms. Conger hit the list with 10 strong concepts, but she also gives great sources to back up her points. Here are her 10 points – click each one to go to the page for more information.

10. Offer Flexible Work Options Some jobs in medical practices are ideal for flexible work options, but most are not. Any position that requires face-time with the patient will likely need to adhere to appointment hours. My question: is it “fair” to allow some positions to have flex-time and others not? If you have a group of people all doing the same general job, letting some people have flex-time and others not may lead to a mutiny. Consider carefully the precedent you are setting when allowing flex-time, and make sure employees understand that as the needs of the organization change, work arrangements may need to change.

9. Practice Open Communication I couldn’t agree with this one more. Communicate, communicate, communicate. One-on-one, in departments, in all-staff meetings, in all-organization meetings. I typically send out an electronic newsletter every Friday (an idea from my mentor, Tom Girton) that announces/reminds people of events, clarifies policies and acknowledges achievements. Oh, and don’t forget to make sure that people are understanding what you’re trying to communicate. Touch base every once in awhile to make sure the message you’re sending is the one they’re receiving.

8. Pencil In Face Time When beginning a new job I often meet with every employee who reports to me (and sometimes meet with everyone in the organization in a smaller practice) for at least an hour to learn a bit about them and hear what they think the practice is doing well, and what the practice could be doing better. Yes, it takes a lot of time, but it starts to form a bond with individuals and it gives me more information that anything else I could do to start to learn about my new group. People are fascinating and I really enjoy an uninterrupted hour with someone – it’s almost a luxury in this day and age. Once you’ve established that bond, make sure to nourish it by connecting with individuals on a regular basis. Letting people know you truly care about them as individuals is how dynamite teams are created. And the karma ain’t bad either.

7. Recognize Success and don’t save it all up! Recognizing efforts, going the extra mile, dealing with a difficult patient, all deserve a pat on the back in front of other employees. Remember to always praise in public and counsel in private. Share the joy of something well done, and let the employee have the privacy of a critique.

6. Set Goals I like to establish individual goals every six months during the annual performance review and six months later during a less-formal touch base. 12 months is a long time to keep a goal in mind, so I prefer to deal with 6-month goals. Performance evaluations should not be a rehash of what was done right and wrong over the year, but rather should be a time to review the goals from the last six months and see what wasn’t accomplished and why, as well as celebrating the goals that were accomplished. See my simple evaluation for more information.

5. Explain the Big Picture I’m often surprised how many medical practice employees don’t understand how their job (especially done well) contributes to the big picture. Check-in staff might not understand how their job impacts billing. Scheduling might not understand how their job impacts the nurses. Nurses might not understand how their job impacts the check-out. No one may understand what their efforts mean to the financial viability of the practice. If all the staff know that they haven’t had raises for two years yet new medical equipment is being purchased for a new service line, they need to have some insight into why a decision was made and what potential it may have for keeping the practice viable.

4. Provide Career Growth Opportunities This fits in well with the 6-month performance evaluation when you set goals with your employees. Goals may include projects, new skills, improved skills, shadowing other jobs, cross-training on other jobs, conferences and workshops, and online or classroom training. Never think that someone can’t do something as predicting success is one of the hardest things in the world. Encourage everyone!

3. Give Employees Respect Give everyone respect. Know that every single person is much deeper than you will ever know and more fragile that you would ever expect. Never forget that you can make someone’s day and break someone’s day. Being a manager is making a choice to care for and respect the people who have chosen to work with you. In many ways, management is the most powerless job (next to parenting) there is.

2. Provide Consistent Feedback For you to effectively provide feedback, positive or negative, the employee must have been trained, must have resources to help them do their job and must understand the expectations of the job. Do not take for granted that your front desk person knows instinctively that your expectation is to have the day’s charges posted and reconciled before the end of the day. Have written performance expectations for each person, then explore the reasons why those expectations are not being met (communication, misunderstanding, workload, etc.)

1. Build Trust I’m so glad Ms. Conger put this as #1 -I agree! Here’s how I build trust: Keep confidences. Follow the same rules I set for the staff (if they can’t eat at their desks, neither can I.) Make promises sparingly and fulfill all promises. Don’t mess up peoples’ payroll or their time off. Understand the details of their job. Don’t allow the doctors or the patients to abuse them.

What’s not on this list that you would add?

My personal list of new employee orientation best practices has been shaped by my experiences in private practices as well as hospitals. Every organization has different resources to draw upon, but each group has core goals that must be fulfilled by a good orientation:

• completion of paperwork including federal and state W-4s, I-9, direct deposit and benefit elections
• emergency contact information (included in hospital employee health intake)
• orientation to the organization, including designations, specialties, departments, sites, affiliates and an organizational chart
• completion of mandatory annual training such as safety, standard precautions, and HIPAA
• mechanics of name tags, parking tags, lockers, keys and codes
• signing off on understanding and agreement to confidentiality, compliance and personnel policies

In addition to these core goals, critical information to be shared during this time should minimally include:

• personnel policy review with emphasis on important (typically abused?) policies
• code of conduct/ shared basic competencies (mission and values, professionalism, communication, chain of command)
• computer security (passwords, internet policy, protection of PHI)
• workstation ergonomics and patient lifting policy (sadly lacking in many medical practices)

Important training that is rarely covered:

• Customer service (what is it and how do we measure our success or lack thereof?)
• Cultural sensitivity and diversity training
• Non-clinical employees’ role in medical emergencies
• Personal safety (coming in early or leaving late, patients threatening staff by phone or in person)
• Expectations for the first 90 days (training, communication, questions, problems)

Making Orientation Memorable

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Most of us have heard that interviewers make up their minds about applicants in the first minutes, or even seconds of an interview. But what about once the applicant has been hired, or even once an employee has been with us for several years? Do we base our beliefs on an employee’s ability to take on a new challenge or improve their performance on something real, or things we believe to be real?

New research shows that managers with a fixed view of people’s attributes tend to “ignore improvements or deterioration in the performance of their staff, and are also less likely to ensure they receive the training they need.” The research findings, reported on the British Psychological Society Research Digest Blog, are as follows:

One study, for example, gave managers negative background information about a fictional employee before they were shown that same person performing well at a negotiation task. Managers with a fixed view of personal attributes (they tended to agree with statements like “As much as I hate to admit it, you can’t teach an old dog new tricks. People can’t change their deepest attributes”) subsequently rated the employee less positively than managers with a belief that people can change.

Another study found that managers who think people’s attributes are fixed gave their staff less coaching, presumably because they think such interventions will be ineffective.

The good news is that once managers become aware of these findings, they can change their minds about employees being able to change and improve! Read the article here.

New employees must complete the new I-9 form (Employment Eligibility Verification) beginning Friday, April 3, 2009. Here is the link for the new form: New I-9 Form

Managers, you do not need to to use the new form for employees whose hire date is prior to April 3.

What is the purpose of the I-9? The form states that it “is to document that each new employee (both citizen and non-citizen) hired after November 6, 1986, is authorized to work in the United States.”

Reading the instructions, I was surprised to learn (more…)

I am very pleased to have had the opportunity to interview Ester Horowitz, the founder and CEO of M2Power, Inc., and the voice of sanity among the current confusion surrounding the Red Flags Rules.

The Federal Trade Commission (FTC) states that the Red Flags Rule:

was developed pursuant to the Fair and Accurate Credit Transactions Act (FACTA) of 2003. Under the Rule, financial institutions and creditors with covered accounts must have identity theft prevention programs to identify, detect, and respond to patterns, practices, or specific activities that could indicate identity theft. The Rule applies to creditors and financial institutions.

Most medical practices have been identified as creditors under the Red Flags Rule. The FTC defines a health provider as a creditor if they “bill consumers after their services are completed. Health care providers that accept insurance are considered creditors if the consumer ultimately is responsible for the medical fees.” Note that being a creditor is not linked to whether you take credit cards or not.

Creditors then must determine if they have “covered accounts.” The FTC states that “A covered account is used mostly for personal, family, or household purposes that involves multiple payments or transactions. This includes continuing relationships with consumers for the provision of medical services.”

Horowitz has written an excellent article on the Red Flags Rule and is receiving calls weekly from medical practices asking her for guidance. She notes that many practices are having trouble distinguishing between the new Red Flags Rule and the existing HIPAA standards, and practices may think that compliance with HIPAA meets the criteria for the Red Flags Rule. Horowitz says emphatically, “There is a distinct difference between PHI (Protected Health Information) and what the Red Flags Rule considers “identity” information.” Although there may be some overlap in HIPAA and the Red Flags Rule, existing HIPAA programs will not be sufficient to keep a practice from incurring fines, if identity theft is traced to the medical practice.

Horowitz outlines the fines as follows:

Employee or Customer information lost under the wrong set of circumstances may cost a company or practice:

Federal and State Fines of $2500 per occurrence
Civil Liability of $1000 per occurrence
Class action Lawsuits with no statutory limitation
Responsible for actual losses of Individual ($92,893 Avg.)

Note the word “employee” in the paragraph above. The medical practice is responsible for the information contained in “employee applications, payroll data, W-2, social security numbers, drivers licenses, and credit cards, military records, and birth certificates” as well as information derived from consumers.

What are the requirements of the Red Flags Rule? A creditor with covered accounts must:

1. Develop a written program, approved by its board of directors, that identifies warning signs and suspicious activity of possible identity theft.
2. Develop measures to prevent identity theft must be implemented.
3. Mitigate damages from instances of identity theft.
4. Ensure that staff is be trained/retrained periodically.

How does one detect identity theft? It is rarely easy, therefore one typically only finds out after the fact. For medical practices, asking for picture ID each and every time the patient is seen might be the only way to determine identity. It would make excellent sense for insurance cards to have photos on them, however, we are all changing insurance policies so often now that this does not seem feasible. Some practices routinely copy the new patient’s driver’s license. Others take photos of the patient and store them in the paper record or digitally in the EMR.

Horowitz points out that fake IDs are quite common, as your teenagers could probably tell you. With the number of people losing insurance coverage when they lose their jobs, can we expect in new black market in fake insurance cards?

The other problem that Horowitz describes is that of mixing care for two different people, one the actual person and the second the identity thief. She notes that practices have a “medical responsibility to find and treat the right person.”

I asked Horowitz about the issue of using the social security number as a patient identifier in medical practices. Many practices require the pateint’s social security number, as it still is the single most useful number for matching patient identities and for collection purposes. She said “Use of the social security number in healthcare is not going away any time soon. Remember that Medicare cards still use the social as its basis. Practices must do everything in their power to limit the exposure to that number and to protect it.”

Horowitz also noted that every system devised will have its thieves – something like “build it and they will break it.” She feels that the critical piece is to have monitoring systems in place to be alerted to the first signs of identity theft so that the ramifications can be minimized. She suggests that practices educate their employees as to the devastating (financial and emotional) effects of identity theft, and encourage personal monitoring programs. Whether a practice decides to provide these programs as an employee benefit is a decision each will have to make. Providing coverage for employees would certainly be a strong indicator of proactive intent to protect the employee if an employee’s identity was stolen from information housed with the employer. Horowitz also recommends that practice provide patients with literature about identity theft (not required by the Red Flags Rule), and especially let the patients know if any process in the practice will be changing (e.g. showing a photo ID at every visit.)

As for the new compliance programs for Red Flags, Horowitz can provide a customized program, employee education, and a monitoring model so the practice is ready for the May 1, 2009 deadline for having the program in place. The deadline is less than 55 days away – do you have your program in place?

More about Ester Horowitz:

Ester Horowitz is founder of M2 Power Inc, and serves as practice marketing and business advisor for the medical industry working with doctors, chiropractors, LCSWs and other health professionals. She helps implement marketing & business actions plans within the professional codes of ethics, HIPAA, and fraud and abuse compliance obligations. Her nationally acclaimed publications focus on the business of medicine and include such articles as The Death of Dr. CEO, How to Find $50,000 in Your Practice, What Does Buying, Selling, and Growing a Practice Have in Common, When Selling a Practice What is Important to Know, a video Raising Capital, and her book The Blatant Truth of Owning a Medical Practice: Rx for Practice Owners.

According to the Bureau of Labor Statistics, “Ergonomic disorders including CTS (carpal tunnel syndrome), various tendon disorders and lower back injuries, are the most rapidly growing category of OSHA recordable injuries and illnesses.”

According to the site Ergonomics in Healthcare

Musculoskeletal disorders (MSDs) account for $1 of every $3 spent on Workers Compensation in America and affect 1.8 million workers each year which many experts believe represents significant under-reporting of the true incidence of ergonomic injury nationally. Compared to other private industry sectors, the medical, economic, and social costs of work-related musculoskeletal disorders or ergonomic injuries in thehealthcare environmentare particularly serious and warrant special consideration.

To protect your most valuable resource, your employees, follow these guidelines and use the links below:

1. Have an ergonomic specialist speak at staff meetings annually to educate your employees on ergonomically sound work habits.
2. As a part of orientation, give new employees verbal and written instruction on arranging their workstations so they can be comfortable and safe.
3. When an employee asks for a new chair, an ergonomic keyboard or a higher or lower desk, arrange for a professional ergonomic assessment (most physical therapy groups can provide this) to ensure the needs of the employee are correctly met. Ergonomic assessments for all employees is ideal, but not always possible.
4. If staff are physically assisting patients or lifting them at all, institute a lift program and make sure you have the correct equipment to protect the staff against lifting injuries. Some private medical practices have a zero-lift policy, which means staff do not lift patients for any reason. Typically, family members and caregivers assist and lift patients in the practice setting.
5. Consider wired headsets or wireless headsets instead of handsets for natural neck positioning when talking on the phone.
6. Always document all efforts to provide your staff with a safe and comfortable workplace.

One of my favorite books of all time is “Effective Phrases for Performance Appraisals, A Guide to Successful Evaluations” by James E. Neal, Jr. I have purchased many editions of this book through the years and I typically supply a copy of it to everyone in my practice who performs evaluations.

The contents of this book include:

• Effective Phrases (in 63 categories including accuracy, development, interpersonal skills, and motivation)
• Two Word Phrases (such as competing priorities, diversified approaches, fully prepared and team performance)
• Helpful Adjectives (such as adaptable, capable, perceptive, and systematic)
• Helpful Verbs (such as accomplishes, adheres, determines, and establishes)
• Performance Rankings (such as exceptional, unsatisfactory, and distinguished)
• Time Frequency (such as always, usually, rarely and seldom)
• Guidelines for Successful Evaluations (rate objectively, use significant documentation and factual examples, plan for the appraisal interview, emphasize future development, and emphasize the positive)

An article authored by Kurt Cagle, online editor for O’Reilly Media, does a great job exploring telework which he defines as

…employees and contract workers performing their work out of the office – from home, from distributed work centers, from coffee-shops, indeed, from wherever those workers may happen to be at the time.

Probably the job most commonly performed off site for medical practices is transcription, with billing a close second. More recently I’ve heard of triage nurses and registrars teleworking and if you think about it, any job that can currently be filled by outsourcing (appointment reminders, appointment scheduling, switchboard, etc.) could be performed by your own employees offsite.

If you’re like me, you may have considered teleworkers for your practice, but worried about managing off site employees and keeping them bonded to the team. Cagle discusses the ever-growing list of technologies available to stay connected, but does not underestimate other problems historically associated with telework.

Telework requires a certain degree of self-starting and responsibility. Ironically, a number of studies, including one performed by Sun in 2007 showed that one of the older stereotypes of teleworkers as people who would tend to do a little work then skip to some other activity, watch TV or surf the web actually proved to be something of a myth – for the most part most teleworkers actually tend to put in longer days working than they would in the office …

Other benefits of teleworking for employees:

• Savings on gas, parking and wardrobe
• Ability to self-schedule
• Gain personal time eliminating commute
• Customized workspace for each person: temperature, light, sound
• Reduction of the carbon footprint

Other benefits of teleworking for employers:

• Saves on expensive medical office square footage
• Fewer distractions could increase productivity
• Allows practice to grow without physical expansion
• Expands employee pool – employees can live anywhere
• Reduction of the carbon footprint

Read the entire article here.

I’ve been very meticulous about not doing anything that has to do with this blog while I am at my real job. I do know, however, that there are others in my organization who do work that is not related to the practice while being paid by the practice.

At a previous job, a newly hired 20-something medical assistant was day trading while he was working the clinic floor. When other employees reported this to me, I was dumbfounded. Not that he was doing it, but that he thought it was okay to do it. And he was surprised that I thought it wasn’t okay to do it. As far as he was concerned, if he didn’t have something to do, he was free to pursue another vocation in his spare moments.

Here’s a partial list of things I’ve seen employees do while on the clock:

• Pay bills
• Balance checking accounts
• Shop online
• Make grocery list or Christmas gift list
• Address invitations
• Answer personal e-mail
• Apply for other jobs
• Look for other jobs for friends and spouses
• Look for new apartments, homes and cars
• Write letters to the editor
• Sleep
• Study
• Read books, magazines, and newspapers
• Plan a wedding (this was a manager!)

My questions are threefold:

What do employers have a right to expect from employees during the workday?

What do employees (of all generations) have the right to do during the workday?

What policies should employers have in place to protect their human resource investment, yet acknowledge the changing needs of employees?

If you have this problem in your workplace, please comment and let me know what your thoughts are.