Start It Up: Staffing - Bring ’Em On

June 1, 2008

The latest installment of our series on starting a practice from scratch offers key pointers on hiring the staff you’ll need.

About This Series
Have you been pondering striking out on your own, making the leap from employed associate to practice owner? Or are you just starting out in practice, and wondering if it’s worth going even deeper into debt to start your own venture rather than getting “a job”?

Whatever your situation, Physicians Practice is here to help with our comprehensive six-part guide to starting a medical practice. In addition to the pre-opening day planning advice you may have seen in other such guides, we’ll delve deeper into the key milestones you’ll need to meet for success long after you cut the ribbon.

You may have heard that hiring staff is one of the later tasks to be completed in the run up to opening your doors. But ideally, that process should begin much further in advance - think months rather than weeks - and be inextricably linked to the raison d’être of your business.

“Starting a practice is a great chance to build your team from the start,” notes Northbrook, Ill.-based management consultant Donna Weinstock. “If you can convey an attitude of what you’re looking for, what your mission statement would be, and have the staff participate in building on it, they feel not just loyalty but also have a stake in [the practice] in terms of wanting it to succeed.”

Lay the groundwork

Your team won’t gel - or indeed even begin to function as a cohesive group - unless everyone has a common vision of where you (and they) are headed. Start by returning to some of the questions you hopefully asked yourself early on: How do I want my business to look and feel? What do I want from my practice five years down the road? Ten years? Where do I hope to be 12 months from now?

You shouldn’t have to change your values to align with job candidates. You may have to think creatively and be flexible about who performs what task, but conceding to a decision that represents a fundamental philosophical shift - or simply straying too far from your preferred path - isn’t a good idea in the long term.

West Virginia dermatologist Beth R. Santmyire-Rosenberger feels fortunate to have figured this out early in the life of her two-year-old practice. “I think you need to develop your personal mission statement and stick with it no matter what you have to do to achieve your goals,” she says. “It is important to know yourself, your ethics, and your values.”

Then, with the help of standard examples readily available online (a basic search will produce plenty of options), you’ll be ready to craft the essential underpinnings. In addition to a formal mission statement for your practice, you’ll need job descriptions and a handbook for employees. “So you’re prepared and are able to hire the right person,” says Weinstock. “Know who you want and what you want.” Too many practices, she says, make the mistake of thinking, “We’ll write a manual later,” or, “We’re too small an office to need policies and procedures.”

Get a running start with a sample handbook (from a site like AllBusiness.com, HRIT.com, or TemplateZone.com), then consult an attorney experienced in labor law. Yes, sorry, you need a lawyer: Information laid out in the manual could later be used to back up an employee’s claim of wrongful termination. Even a simple statement could be misconstrued. For the same reasons, you’ll also want to include a disclaimer stating that the book does not constitute an employment contract.

Make sure job descriptions, meanwhile, are oriented toward the results you expect rather than just static lists of responsibilities. A group called the Job Results Management Institute, whose founders have authored several books on job descriptions and employee performance, suggests on its Web site the following example for a medical assistant:

Job purpose: Helps patients
By arranging examining room instruments, supplies, and equipment; greeting patients; confirming purpose of visit or treatment …”

Under the list of “essential functions” for this employee fall generalized tasks - the results the MA is expected to achieve - followed by the steps they’ll take to accomplish them. This MA will prepare patients for their visits “by directing and/or accompanying patients to the examining room; providing examination gowns and drapes,” and so on.

A document crafted in this deliberate fashion helps staff understand where they fit into the practice’s mission, and makes crystal clear their contribution to it. The MA above, for instance, is told that he is expected to generate revenues by recording billing data and answering payer inquiries.

Refer back to the job description when conducting all subsequent employee reviews, updating it when circumstances require a change in the duties assigned to a particular position. And although it sounds like nothing more than a cover-your-duff move, add “and other duties as assigned” to the list, and let employees know that their jobs will change over time. A staff member who continually uses the job description or other documents to back up a “that’s not my responsibility” stance is someone you - and your patients - don’t want working in your practice.

Experience counts

First on the list of the folks you do want in your practice should be someone who can ensure that operations run smoothly, allowing you to focus on your patients. According to Sheri Poe Bernard, vice president of member relations at the American Academy of Professional Coders, a certified coder may be the best fit for this role, at least initially.


“A lot of what we do in coding and reimbursement ties into that business component,” she notes. “A great part of it is making certain that the front office is running smoothly. An even bigger part is the whole reimbursement picture and making sure that [you] understand both compliance and charge capture. It’s kind of a thin line: You want to follow all the payers’ rules but also capture everything you can to get paid what you deserve.”

Others say the office manager should be the first hire if you’re starting small. Particularly in a single-physician practice, that person and the coder could be one and the same. In all but the most lavishly financed practices, staff (and physicians) will have to fill more than one role in the beginning - this person can manage billing and other tasks until revenues increase sufficiently to allow for more hires.

Even when you expand, you’ll want to be able to head off scenarios like, “Susie just quit with no notice, and she was the only person who really knew how to use the billing software!” Provided you’re able to keep accountability clear and the reporting structure transparent, cross-training of employees is often a good idea. The payoff of avoiding disruptions down the road is well worth the effort.

Even though she had “zero patients,” Santmyire-Rosenberger started her practice with three experienced employees, including an office manager who handles billing and collections. At first, she says, she considered that position a luxury. Now she views her office manager as an absolute necessity, particularly with a staff that’s increased to five.

“I could do it with a lot less - I could run my office on a daily basis with two people,” she says. “But would people get their questions answered? Would patient waits be as short as I want?” By maintaining a sharp focus on what she considers the keys to good patient service, circling back to the mission and vision, Santmyire-Rosenberger is able to keep things running smoothly while turning a healthy profit.

‘New practice seeks dynamic professional… ’

The experts are unanimous: Do not skimp on staffing. You may find it necessary to pay a little more to hire the right staff, or to invest more in the long term to help with the professional development of someone less experienced but with the right attitude and intellect. The latter course may be your best bet in rural areas or those suffering acute staffing shortages.

Either way, “You get what you pay for,” notes Poe Bernard. You could bring in a family member to help you get along, but hiring people who lack key background knowledge, particularly when it comes to finances, usually results in one of two equally untenable scenarios: (1) putting yourself and the practice at risk (either through inappropriately low charge capture or fines/takebacks for incorrect charges), or (2) expending the invaluable resource of the physician’s time resolving matters that should be delegated elsewhere. “If you want to hit the floor running and start your practice with a full schedule and a robust patient load,” says Poe Bernard, “you’re going to have to have somebody competent in place.”

Finding such a person isn’t easy, and formal credentials are just a starting point. In fact, you’ll want to confirm with the issuing institution all credentials and degrees an applicant claims. Falsification of this sort happens astonishingly often, and practices could save themselves a heap of trouble by checking the facts before making an offer. Background and credit checks are a must as well.

Half of all practices will experience embezzlement, the highest rate of any service-sector business. This crime usually goes unreported (or unnoticed), but don’t risk missing a rap sheet. A credit report, likewise, may not turn up much. You’ll probably want to know, though, if your prospective billing manager carries a $50,000 balance on her Neiman Marcus card.

Formal references are falling out of favor as applicant-vetting tools, as the legal ramifications of giving a negative reference can make it difficult to get meaningful information out of former employers. Or, says Poe Bernard, “They doom you with faint praise.” It’s nevertheless worth asking for professional references and calling to follow up. What someone refuses to say about a colleague can tell you plenty.

A candidate’s attitude, work ethic, and maturity level should carry quite a bit of weight in hiring decisions, too. Just don’t get too chatty when seeking clues to this subjective info, as that’s often when interviewers run afoul of labor law by asking about personal matters such as age or marital status.

If you elect to outsource nonclinical work - and plenty of practices do so quite successfully - rules similar to those outlined above apply. Before farming out billing, IT, or even many human resources functions (through an entity known as a professional employer organization), ask plenty of detailed questions, follow up on references, and remember that cheaper is often not better.


According to Weinstock, one of the biggest mistakes doctors make is being unwilling to pay for what they need. “If people feel like they’re compensated and appreciated, they’ll work a lot harder,” she points out. “If you find the right person and you’re not getting them because of a dollar an hour, that’s not worth it.” You’ll likely be able to find someone willing to sign on for that lower amount, “But you want to make sure you’re hiring the right person.”

Once you’ve found that person, remember that she’ll need continual training and feedback. “In essence, hiring is only part of what you need to do,” says Weinstock. “The other part is to give your new employee the tools to succeed.”

Laurie Hyland Robertson is a senior editor with Physicians Practice. She can be reached at lchrobertson@physicianspractice.com.

This article originally appeared in the June 2008 issue of Physicians Practice.