, LFACHE, CHBC is a consultant, author, speaker and professor with more than 50 years of experience in healthcare administration. He is an independent consultant based in The Woodlands, Texas.

Owen Dahl

How many of you have had turnover, Covid and other illnesses, care for family issues, other organization pirating our staff, work from home (WFH) issues, burnout, and employees leaving for hire paying jobs? It seems to be a never-ending battle to deal with employees, turnover, burnout, and related stress. Turnover is expensive. The Society for Human Resource Management estimates turnover costs between 70% and 200% of an annual salary due to recruiting, interviewing, training, and lower productivity rates – you don’t write out a check for that amount, you just use or loose resources. What can be done to retain physicians and knowledge workers?

First is the hope that your hired right! If you are looking to hire, do it right!

An acronym that works for retention is CREATES! The breakdown is as follows.

 is for culture. How has your organization dealt with masks, vaccines, time off, wage and salary adjustments and bonuses? Have you been consistent, effective in communications, and transparent? Is your mission clear, understood, and lived? There is no right or wrong approach, just how your organization has done it.

 is for reward. What has been done for wage adjustments? How about recognition for staying, for a job well done? Recognition is accomplished with money true. But that is a small but necessary part. Customized benefits where you understand the needs of the various generations and so much more, read on.

 is for engagement. Do you listen to employees? Do you recognize their individual contributions to the success of each patient visit? An engaged employee, one who buys into the mission, sees a purpose for their efforts in improving patient care, and achieving a level of personal satisfaction is critical to your success.

 is for attention. Effective communication and transparency. Effective through various means including one on one exchanges, meetings, emails, texts, and the like will get and keep the focus on your mission.

 is for teach. Younger employees are hungry for more knowledge and for personal growth and personal development opportunities. A learning organization focuses on formal training, mentoring and effective coaching.

 is for execute. One of the biggest reasons employees leave is due to poor management. Doing none of the above. Are you a Theory X manager – authoritarian, micro-manager? Or a Theory Y manager – open, delegator? Now is a good time to take a serious look at yourself and how you work to develop managers, supervisors, and lead workers who you work with.

 is for schedule. Flexible time is critical for all. This includes days of or hours away to care for a circumstance outside of the office that is important to the employee. A goal of work life integration, going beyond just balancing.

This all leads to a question of meeting individual, yours, and your staffs, well-being. Gallup defines well-being around five major factors: career, social, financial, physical and community. An effective approach that CREATES a retention strategy will reduce costs, improve patient retention and treatment plan compliance, and well satisfied employees served by your medical practice.

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A simple acronym can help your practice retain staff.


CREATES: An approach to employee retention

You may think workplace violence would never happen in your office, but the same can be said for flooding, wind damage and other natural disasters. Workplace violence is possible anytime, anywhere.

 (SHRM) defines workplace violence “as a spectrum of behavior…that generates reasonable concern for safety…physical and mental…for patients and employees.” Given this broad definition, workplace violence is not just limited to an active shooter situation. Bullying, harassment, physical abuse and verbal abuse can all be considered workplace violence.

Perpetrators of workplace violence can include employees who are dominant in words and actions, get upset easily, have issues at home and bring their attitude to work and act from a position of authority. They can also vendors, patients, patients’ family and employees’ family.

There are warning signs for possible workplace violence to watch for, including difficulty getting along with others; negative and non-supportive attitudes; odd behaviors such as being childish, pouting and generally non-supportive of the practice mission a physician or even fellow employees; recent layoffs; and controlling behaviors. Staff may be attacked, patients may be threatened, patients (or a family member) may come back and threaten and someone may lose control or turn violent at any time.

News of a shooting instills both shock and fear when it occurs in the workplace, nearly always with devastating results. But a shooting doesn’t have to result in casualties. Don’t wait for tragedy to strike to start preparing. Your medical practice needs to have a workplace violence prevention and response program in place.

Here are some key steps you can take to protect your patients and staff:

establish a zero-tolerance policy for violent behavior by adapting a clear code of conduct;

form a prevention program through effective communication;

train staff to be aware of the potential during onboarding and include in your annual training along with OSHA, HIPAA - it’s that important;

review your insurance coverage, including liability, physical damage and business interruption; and

Take an in-depth tour of your facility to assess lighting, access control, badges, keys, alarm systems and review security video, especially if you are part of a medical office building. Encourage employees to report to their supervisor or to the compliance officer, who should log incidents; identify trends; report incidents to local police if necessary; and offer intervention including medical evaluation as needed.

 that is well worth reviewing in detail. Impart to your staff that if confronted by an active shooter, they should:

hide – move so you are out of the shooter’s view and

fight – confront the active shooter as a last resort.

Occupational Safety and Health Administration

 also have a great deal of material available to help you plan for a number of possible workplace violence scenarios.

What is done after the incident is critical. You should offer psychological support for those involved, both directly and indirectly. Your compliance officer, practice leadership and board of directors should review all incident(s) in detail to determine what happened and how to prevent similar incidents from happening again. Prepare for how the issue will be communicated to internal staff, patients and the general public. Ask external resources for assistance dealing with the after-incident event, such as the local police department and counseling services.

Workplace violence can - and does - cause stress, turnover and create an uncomfortable workplace for staff that can impact patients. Do not think that your practice has not or does not have incidents of workplace violence. These situations do occur and are often swept under the rug or ignored and thus tolerated. There are likely signs that need to be addressed honestly and thoroughly to ensure you have a safe, secure and comfortable workplace for both your staff and patients.

Learn how to identify signs of workplace violence and how to respond to a potential threat.

Workplace violence: It could happen to you

When a mistake is made, very often the blame is pointed at 

did it, and that person is held accountable regardless of the reason behind the mistake, the severity of the incident, or past performance or actions. Too often the reaction to an employee error is to begin the process of termination, and in some cases, it is immediate! But this is not the best action to take in the majority of the incidents.

Constant staff turnover results in increased costs and reduced patient satisfaction. Hiring and training new staff members and the varying levels of new staff productivity can deplete up to 70 percent of a practice’s revenue. And patients gain a negative impression of the practice when they are greeted by different staff members at each visit, and there is no opportunity for patient and staff to establish relationships if there is always someone new. 

A better solution when confronted with a mistake is to ask 

 of total quality management fame suggests that only 15 percent of the mistakes made by employees are their fault. Rather, 85 percent of the time, it is the fault of the “systems,” which includes the training and tools supplied by the practice.

Don’t stop at the first why; drill down to the second, third, and up to the fifth. Why did you do it that way? (That’s the way we’ve always done it.) Why have you always done it that way? (That’s the way others were taught.) Why were they taught that way? (That’s the way Jane was taught, and she taught me.) Why was Jane taught that way? (That’s how Peggy, who left the job five years ago, did it.) Once you get to the real issue or reason why, it is then possible to determine the necessary corrective action steps.

How do you go about this? In asking why, be prepared to lead or direct the question to the root issue involved with the situation. This will require active listening and not jumping to conclusions. Often, we think that the issue has been identified with the first or the second question and decide to not delve further. Be patient in asking the questions. 

Once the core why is understood, work with the staff to determine the solution to the problem. Ask “how do you think we can fix the situation?” or perhaps, “now that you know the reason, give it some thought, and we can talk about it again tomorrow.” Staff members often have greater insight into what steps would improve their workflow and are more likely to engage with the solution when they have a voice in the process (versus the solution being dictated by upper management). Follow up in a couple weeks to assess the effectiveness of the solution and ensure that the correct why was identified and corrected.

You cannot avoid employee mistakes, but you can make sure the same mistake isn't made twice.

The why matters 

The dynamic, ever-changing value-based payment model creates a more complex world for the revenue cycle team.  

Value-based care raises many reporting questions. How and when do/can you record adjustments? How about payments offered in an explanation of benefit (EOB) that does not include a summary? How do you assign payments to the correct provider when the compensation model is based on work relative value units (wRVU)? What does changing when adjustments are posted mean in terms of reporting and tracking the effectiveness of the revenue cycle program?

First things first. Do you have or are any of your payers suggesting they will be shifting to a capitation payment model? If so, lots of technical discussion between the practice and the payer should occur about payment timing and reporting. You might feel like you don’t know where to start, so begin by analyzing the payer’s current EOB format and a sample of what the capitation EOB would look. This will reveal details about what to expect in terms of patient and transaction detail.

You then need to reach out to your practice management system (PMS) vendor. It’s essential you ask them what tools they have and how they process the entire transaction. Their answers could be a huge help in determining your best approach to addressing the charge posting and EOB processing.

Then, you’ll want to shift gears to the internal processing of these value-based transactions. Your current approach to managing your charges, payments, and adjustment (CPA) is to take action when services are provided and when EOB’s are received. Each patient account is accessed, charges are entered, claims are submitted, and EOB’s are posted with payment and adjustment amounts. Further actions are taken as necessary, e.g., appeal, statements, or close out the transaction. Daily or monthly reports are updated with each step. The accounts receivable balance is tracked until the transaction amount is zero. That workflow doesn’t apply in a capitation care model.

In a capitation world, payments are based upon the number of patients assigned in your panel and are processed monthly. Your practice needs to ask a key question: Do you write off, in other words use capitation code, when the charge is posted by track each provider’s activity rather than dealing with the charges at a later time? 

If you do, then when payments are received, rather than post to the patients account, the amount is posted to a capitation account per provided (if the EOB identifies what amount is for which provider). Again, your PMS vendor may already have an ideal option that you could apply to your workflow.

This change however, will have a ripple effect in your reporting since payments and adjustments are taken at the time of charge posting. Your accounts receivable balance will therefore be reduced, and the traditional reporting will reflect an improved collection percentage. Here’s something to consider: Do you then change your charge posting process for all transactions and take adjustments at that point?

Before making any changes, make sure you understand and have a consistent process for handling copays and deductibles. The payer should help with a standard, e.g., $10 copay for each visit that will make tracking and collections a little easier. If there are a variety of copay plans, you may have to set up different “payers” in your master file even for a single payer, e.g., payer A $5, payer A $10, and so forth. 

There is also the question of carve outs for when you have negotiated a fee-for-service arrangement for certain procedures according to Current Procedural Terminology codes. These would be handled in a more traditional way. Therefore, you may have a patient with a $5 copay for an office visit as well as a carve out procedure.

I know I may be confusing you rather than giving you all the answers. However, serious discussions and analysis should occur now, so you are ready to proceed when the optional payment models are presented.

I recommend you take these four steps today OR sooner rather than later:

Determine how you accept capitation payments.

Learn the payer process and know how the payer will inform you of the patient panel and EOB.

Seek advice from your PMS on handling these types of transactions.

Identify what changes need to be made in your internal processing and reporting.

There is no one right way to proceed. If you think through these key points, you will be prepared to handle the various payment methodologies you are, or will soon be, facing.

How do you post charges, payments, and adjustments in value-based payment models?

How to prepare for a capitation payment model

The recently completed baseball playoffs offers us a great perspective to review two key approaches to improving performance: coaching and mentoring.

Each team has several coaches that work directly with the players on the field. A coach’s job is to teach, support, and, in certain cases, provide constructive criticism. They do not go onto the field after a play but utilize the breaks between innings to give instructions or reinforce what was done well.

The team also includes players who have a great deal of experience and those who are “rookies," or new to the team. Rookies can learn lot from experienced players in key situations during a game. In addition, there is a lot to learn about the “culture” of the team–how everyone relates to each other, nick names, strengths of each player, suggestions on how to approach a key situation again (based on experience), and the coaches’ communication styles and decision-making process. Experienced players can help to support the growth and development of rookies by sharing tips on how to succeed, how to fit in to the team culture, and to answer questions when they arise.

It is important for the leaders of a medical practice to know if they are good coaches. Coaching is done by those in positions of authority as it is their direct responsibility. The purpose of coaching is to improve skills and knowledge of team members in order to elevate the entire team’s performance.

However, in order to develop the best team possible, leaders need to harness the knowledge and skills of the experienced team members and pass that information along to new members. This can be done effectively through mentoring programs.

Successful mentoring programs are formal in nature. Leaders can select respected employees with the right skills and experience and pair them with newer members of the team. The mentor does not have direct authority over the mentee. Instead, mentors act as internal advisors, helping mentees to integrate into the team.

Mentors share what has worked for them and the best ways to deal with key issues that surface throughout the clinic at any time. They also have more time to get to know the mentee, allowing a greater focus on the human relations aspect that leaders or coaches may not have the bandwidth for. The formal program may last only three to six months based upon an agreement that is signed initially, but the relationship can continue informally as long as both employees continue with the practice.

As we look to the future with the Millennial and the Gen Z generations becoming a significant part of our workforce, the development of a formal mentor program is a very real option to retention and improved performance.

In order to foster high-performing teams, organizations need both coaches and mentors.

Coach vs. mentor

How clean is your desk? Your work area? Those items that are in your work area, are they necessary to have where they are or are they in the way? When you enter an exam room, is everything in its place and are all exam rooms stocked in exactly the same way?

These types of questions may seem trivial, but they are not. Consider the amount of time your team wastes looking for items that are out of place, which detracts from the time they have to spend with patients. When accumulated throughout the day, this wasted time contributes to longer wait times for patients, which leads to reduced patient satisfaction scores. 

There is a simple solution: the 5S methodology!

: Determine the essential and non-essential items. Eliminate the non-essentials.

: Store the essential items in the right place.

: Establish direction to make the first three steps a habit.

: Create a system to ensure the success of the methodology over time.

. This step could be incorporated with Sort as you would redesign your workspace to reduce the number of unsafe incidents that occur.

To get started, first try implementing the 5S methodology at your own private work space. Is the surface clean? Are the necessary items in drawers, shelves, or baskets that are easily accessible?

To do this in a shared space, such as the nurses’ station or exam room, you need to all team members to be in agreement. Convene a meeting or two to review the methodology and reach a consensus. Be prepared that individuals may have different views on how items should be organized. These discussions may not be easy, but once everyone gets the hang of the steps, they will see the benefits.

The 5S methodology may seem overly simple, but it can and will save time and resources, which will lead to improved patient care and patient satisfaction.

To understand what a positive impact the 5S methodology can have on your practice, track for a few days the number of times you either looked for something or handled an item more than once. The accumulation of this wasted time and energy is measurable and can be shocking once identified. Use this measurement as a benchmark, and over time you will realize how the 5S methodology helps you see more patients or get out of the office on time.

Looking for a way to help yourself and your staff be more productive? Look no further than these five steps.