Above all else, personnel and the human element of any clinical practice will drive its success. Management is one area where the art to medical science comes into play; it requires a significant time investment and is the area most likely to provide a return on investment than any other aspect of clinic management. People make the business. From the provider and their staff to the patients and their families, having the right people on the team will make all the difference.

Whether a physician is in private practice or joins the faculty of a large academic medical center, their role in clinic is inherently that of a leader. The physician sets the tone for a practice, and support staff will revere and respect a physician who is a good leader. What good news for the ego, but the responsibility that comes with this role cannot be underestimated. Leadership is refined with experience and does not come naturally to every medical school graduate. It is worth the time and energy for physicians to hone their leadership skills and work towards greatness in this regard. Top leaders are “differentiated from other levels of leaders in that they have a wonderful blend of personal humility combined with extraordinary professional will. Understand that they are very ambitious; but their ambition, first and foremost, is for the company’s success. They realize that the most important step they must make to become a Level 5 leader is to subjugate their ego to the company’s performance. When asked for interviews, these leaders will agree only if it’s about the company and not about them” (1).

Beyond the physician, the people supporting their provision of care carry tone and culture throughout the practice. Relationships between the physician and patient are pivotal, but the amount of time patients spend interacting with the clinic staff far outweighs time spent with their physician. A positive patient care experience hinges on whether each team member they interact with consistently demonstrates helpfulness and kindness and promotes an environment of safety, security, and confidentiality. Hiring staff who subscribe to common philosophies on customer
service and priorities in the workplace forms the foundational stability for a thriving, oftentimes unpredictably busy clinical practice.

In addition to hiring the right people for the right roles, it is important to rightsize the number of employees. There are several organizations in the market that offer benchmarking data for staffing levels. It is important to gauge, but difficult to compare unequivocally to other practices, as support needs vary widely from practice to practice and will depend on several factors.

Patient volumes, socioeconomic characteristics of the patient population, mix of services provided, and even the physician’s personal style of practice all factor into determining the right number of support staff per physician. Key operational roles include registered nurses (RNs); licensed practical nurses (LPNs); medical assistants (MAs); and nonmedical administrative support including management, schedulers, patient accounting, housekeeping, information technology, and medical receptionists.

Retention of excellent employees saves a practice both time and money and improves the quality of care. National studies have estimated the average cost of replacing an RN to be anywhere from about $22,000 to over $64,000 (2). Turnover costs are estimated to range between 0.75 and 2.0 times the salary of the departing individual (3), while nurse turnover costs have been estimated at 1.3 times the salary of a departing nurse (4). Patient care can suffer when the nursing and administrative staff members are inexperienced or unfamiliar with the clinic operations.

Beyond just being a great leader and setting a productive cultural tone, there are tactical strategies to retain good people. Making the financial investment in your staff is the most obvious. Paying market-competitive salaries that keep pace with inflation and offering a competitive benefits package to supplement take-home pay are strategies. People are also motivated by nonmonetary rewards and recognition that can be as simple as a note of appreciation when they’ve done a good job or getting recognition for making a positive impression on a patient. Retention is not a mystery—consider what drives each individual on your team and ensure that his or her intrinsic needs to be a happy and productive employee are met. Support the sharing of ideas, get to know staff, and listen to their concerns. Provide opportunities for their personal and professional growth. These are valuable investments in the core of the clinical practice, the people.

Access to health care has sparked ongoing debate and political division in the United States for years. Physicians are inherently committed to treating patients who come to them in need of care. However, health care professionals are not immune to economic realities. In the current system, the cost of health care often exceeds individual affordability. While many Americans have insurance coverage, there are a vast number of individuals and families who do not. There are also people with high deductible insurance plans who, while covered by an insurance plan, will struggle with affordability. Health care providers must balance both missions: to provide care to those in need, while remaining viable as a business and able to sustain continued services over the course of time. Increasingly, ethical pressure builds on the physician to walk this fine line.

One method used to promote sustainability is to divide a portion of patient appointment slots between various payer classes. This mechanism builds in both the accommodation of patients with a variety of payment sources as well as the funding from enough insured patients to sustain the practice.

Logistical access points are another component of access to health care. Requests for physician services come from a variety of constituents: referring primary care doctors, referring specialists, their office staff, and patients themselves. To accommodate all requests, it is advisable to develop policies and consistent protocols around both who is authorized to refer a patient to the clinic and what process they must follow to do so. For example, if a referring physician calls to request an appointment for one of his or her patients, copies of applicable clinical information from the patient’s chart will need to be sent prior to the appointment. Labs or other ancillary test results from outside sources will avoid ordering duplicate studies or tests and achieve a continuum of care for the patient. Such policies must be built in advance and adhered to consistently in order to ensure equity in access. Another consideration in access points is how requests are received—whether by inbound phone, fax, e-mail, or other mechanisms, a quick turnaround and bidirectional communication with the requester is important to promote access and survive in a competitive market. Acquiring a reputation of being difficult to access or slow to respond to appointment requests will quickly drive referring physicians to send their patients elsewhere.

Scheduling template design is also critical. It impacts not only revenue but also clinic throughput, efficiency, staff morale, and patient satisfaction. Length of appointment will naturally vary by provider, but a good rule of thumb
for a new physician starting to build the practice is to allot 15-minute increments for every standard patient visit. The template can be adjusted accordingly to properly account for a typical new or established patient visit with each provider.

There are several examples of template design techniques that can be used to promote access, the most common include

Once an appointment is scheduled, the process to obtain approval for any procedures should begin immediately. The difficulty for physicians in this system is that each insurance company typically develops a unique set of rules around which procedures require an authorization, the process physicians must follow to obtain pre-approval, and even the level of detail or data sets required to obtaining an authorization. The best approach is to have dedicated office personnel for this function who can become familiar with each of the rule sets, keep abreast as they change, and allow as much time as possible to follow their protocols before a service is rendered.

The patients’ arrival to the clinic presents a prime opportunity to validate their demographic and insurance information. This information must be accurately captured to process medical claims or advance their account through the collections cycles for payments due after the date of service. Many insurance companies provide eligibility verification tools on their Web sites, or there are clearinghouse vendors whose technology will automatically validate discreet data fields against various insurance company databases to guide correction of inaccuracies.

Physicians in training are often criticized for the time it takes to do many of the things they have been taught to do well. For example, documentation that is thorough and detailed takes time, as does visiting with a patient during a routine evaluation and management visit. However, in order to stay afloat, a clinical practice will survive off volume. As long as the reimbursement environment is based on a fee-for-service infrastructure, the more services a physician can provide in a day, the more financially viable the physician’s practice will be. The challenge for physicians is to find balance and work towards efficiency, trimming any wasted time from the day. Clinic layout and flow is one way to save steps for physicians, nurses, and other support staff. It is important to have the right number of support staff, but each one must have the ability to do his or her job efficiently and without, or at least with minimal, waste.

Bottlenecks can arise in the physical layout of the clinic space, the stocking and flow of medical supplies and equipment, or even in the logistical characteristics of the support staff. For example, to run two exam rooms in parallel, the vitals station must be set up to filter patients through from the waiting area to exam room in a timely manner. Having a vitals space that is in an awkward location or having too few staff to support patient movement through the hallways can result in exam rooms sitting vacant for periods of time or worse sitting idle with waiting patients inside. Flow diagrams, Pareto charts, spaghetti diagrams, and process time studies are all excellent continuous quality improvement tools available to help troubleshoot clinic flow issues.

It will be obvious that there is a problem; the difficulty comes with identifying the root cause and implementing and monitoring the fix. Successful improvement initiatives begin with a clear goal and an understanding of the information needed to identify and monitor measures of resolution. According to Raymond Carey, “The goal of data collection is to gain an objective view of the process under investigation and to understand how it is performing over time. The healthcare field is replete with data. Few industries collect as much data as we do in healthcare. The problem we face, therefore, is not a data problem, it is an information problem” (5).

Health care is an amorphous industry, one in which the physician and their support team must continuously evolve to meet the needs of their customer. Clinic operations management is complex in that it requires standardization
and structure, while remaining flexible enough to adapt as the regulatory, technologic, financial, and medical environments change. Leading change is a critical skill for physicians in light of this challenge.