“There’s no problem with the patient care here,” Angela Gondo says. “How to get the system working is the main thing.” But “the system” can’t be separated from good patient care. The practice’s all-things-to-all-people manner of care delivery hinders the implementation of any sort of system — and that, in turn, does inevitably have some impact on patient care. It’s time for Gondo to start thinking of the business of medicine as entwined with the practice of medicine — rather than perceiving business-imposed constraints on health care delivery as an insurmountable barrier.

Scheduling a follow-up appointment to discuss a patient’s hypertension if he’s currently in your office for a work-related injury doesn’t constitute poor care. But lumping such a complaint in with the documentation for the injury, as Angela Gondo tells me her husband has done, isn’t good for the practice’s reimbursement or the patient. She feels the practice needs to find a way to respectfully let patients know they’ll have to come back to address concerns beyond those they came in for. “We’ll need to schedule you another appointment to allow us to give that issue the full attention it deserves” ought to be a phrase Gondo teaches his staff to use.

Sometimes, of course, it does make more sense to address all of a patient’s issues in one sitting, provided Gondo documents everything. If he spends more than 50 percent of a visit consulting with a patient, he can bill by time — that is, at a higher E&M level. Rather than billing a Level 2 code twice on two different days, he can bill for a more complex Level 4 or Level 5 visit.

Staffing Headaches

In the beginning, it was one line on Gondo’s Practice Makeover application that led Physicians Practice to his doorstep: “All my staff walked out on me five weeks ago.” A scenario like this is the stuff nightmares are made of for many small business owners. Even considering the charting chaos, both Gondos say staffing is their biggest stressor.

A mass exodus might have everything to do with the employees, not the employer, as Gondo says is true in this case. (Litigation is ongoing.) The practice has had trouble retaining staff in the past, however, so it’s difficult for us to sort out this specific situation. In any case, it’s always wise to hold exit interviews with departing staff members to examine their reasons for leaving. (These can be useful even in cases in which an employee has been dismissed.)

A word on the spouse as office manager, about which we atPhysicians Practice hear a lot: Although this works amazingly well for some families as a permanent arrangement, it’s usually best employed only as a stopgap. When a spouse fills the top management role, the vested interest that person has in the practice can lead to undue interference with other staff members’ activities. The physician is busy taking care of patients — or should be — but the spouse must deal daily with employees who might not perform revenue-enhancing tasks the way the spouse would. It can be difficult for staff to take concerns to the spouse, too, leading to the physician’s over-involvement in human resource matters.

The Gondos are at a turning point — the practice has become busy enough for them to evaluate where their family business is headed, and under whose stewardship. In fact, Angela says she’d like to step away from the practice within a year. For now, Gondo seems to have conflicting feelings when it comes to his wife’s presence. Angela has no clearly defined role in the practice’s day-to-day operations; she doesn’t even have a firm job title. Although Angela refers to herself as the office manager, Gondo says she is the “acting business manager” and has apparently told previous employees that she is not the manager. Although a consultant has helped the practice revamp its policies and procedures manual, the practice’s list of job descriptions doesn’t include one for an office manager (or business manager).

“I do too much in the office,” Angela says. “I have a habit of covering every area because I was doing it at the beginning.” Peralta, the practice’s former medical assistant, notes that the office had become an extremely stressful, chaotic environment by the time she left three years ago. Angela knows this, and she wrings her hands as we talk about the practice’s various operational hiccups.

The Gondos say their previous staff — those in the round after Peralta left — often used divide-and-conquer methods. As Angela puts it, “They ganged up against us.” The physician, though, doesn’t seem to recognize that he’s enabling this behavior by not supporting Angela. While Angela remains in the practice, Gondo needs to back her up 100 percent, which may mean spending more time after hours strategizing as a team.

Angela, who offers insight after insight into the practice’s operations during our conversations, may be better suited to a strategic planning role. She points out that her husband needs to help the staff to function as a team, saying he “is the captain, and he needs to set the direction.” She repeats this plea for focused leadership several times during our conversations. But this ship’s captain is occupied with serving the passengers cocktails — worrying about details like punctuation, office supplies, and the mail — rather than steering the ship.

Staff-wise, things are looking up now, but Gondo will have to radically change his habits if he hopes to hang on to his two new employees. Nina Ocampo, the practice’s friendly receptionist, had been at the office for only a month at the time of our visit and already was a patient favorite. And the fact that she’s bilingual is invaluable in the practice’s culturally diverse region.

Pearcey, who has more than 20 years of experience as a medical assistant, is helping Gondo get the exam rooms in better order, improving follow-up tracking of patients through a calendar program, and implementing process improvements wherever she can. She’s been with the practice for three months, and Gondo plans to eventually give her more management responsibilities.

He may have been forced to do so in the past, but when Gondo opens the mail today — a favorite pastime, according to Angela — it’s a source of frustration for the staff. They know that while he’s reading the mail, other tasks remain undone.

Laurie Hyland Robertson is a managing editor for Med-IQ, the parent company of Physicians Practice. She has been in the medical publishing field for nearly 10 years, working editorially on both clinical and management topics. She can be reached at lrobertson@med-iq.com.

This article originally appeared in the October 2006 issue of Physicians Practice.