Staff turnover may be costing your practice more than you think. In addition to putting a considerable dent in the practice pocketbook, it is also costly in terms of patient and staff satisfaction.

According to The Health Care Group's 2001 Staff Salary Survey, turnover is highest among receptionists, but it's a problem for many other positions as well. A general rule of thumb for determining whether your practice is experiencing high turnover is to look at the percentage of staff your practice turns over in a five-year period. In my experience, 15 percent staff turnover in five years is reasonable; 20 percent or more is considered high. [See the box to learn how to calculate your practice's turnover rate.]

Fortunately, by critically evaluating the positions in your practice and soliciting feedback from your staff, you can uncover the sources of turnover and make your practice a place where people want to work. The key is to put yourself in their position, literally.

Evaluate positions one by one

Because each position is different, it's best to evaluate one at a time. The examples in this article focus on the receptionist position, but the process can be applied more broadly. The evaluation of a particular position should be done by the position's immediate supervisor, which may often be the office manager or sometimes a physician, depending on the position.

Before you get started, try to gain as much cooperation and input from the staff as possible. Assure everyone that the mission is to help you understand their jobs and identify what can be done to make things easier for them. Also, be sure to involve the staff in every step of the position evaluations, including development of potential changes to the position.

Begin by spending half a day observing the employee whose position you're evaluating, noting what tasks he or she takes on and under what conditions. It's best to conduct the assessment on a typically busy workday. As part of your observation, ask yourself the following five questions. The answers will help you understand why staff in this position leave and how you can reduce turnover:

1. Are you creating a desirable work setting? Work environment plays an important role in staff job satisfaction. This includes everything from having the right tools available to providing basic comfort, such as proper lighting and noise control. Staff members also need to have ergonomically designed work stations that include a comfortable chair that's the proper height and distance from constantly used work equipment such as the telephone and computer. It's also important to ensure that the work area is laid out logically and efficiently.

While observing the receptionist, look at the front-office layout. Is it noisy and chaotic? Do staff members congregate at the reception station to visit or use the copy machine? Do nurses stand there to review charts on arriving patients or access a computer to schedule a work-in? Do billing staff use the area for discussing insurance issues with patients? Do file clerks gather there to discuss missing charts or dictation?

If so, easy solutions can be implemented to improve the situation. For example, make sure the arrival counter where patients check in is situated within three feet of the receptionist's desk so that patient-receptionist interaction isn't strained; place a computer terminal in the nurses station for easy access to charts and/or scheduling; and instruct the billing staff to discuss billing issues in a more appropriate location. As for the copy machine, it may be wise to relocate it or consider purchasing a second copier in a department with high-volume needs. It might also be worthwhile to invest in a telephone headset for the receptionist to make telephone conversations easier.

2. Are tasks appropriately assigned and performed? Compare the job description for the position with what the staff member really does. Determine whether the work that staff member is doing is appropriate to his or her position. Would it make more sense to have someone else in the office do it?

For example, if the receptionist is constantly being interrupted by incoming phone calls while trying to assist arriving patients or is having to leave the reception station repeatedly to look for charts, you could ask someone else to triage incoming calls and require that file clerks retrieve the charts. This way the reception station won't be abandoned, and the receptionist can take on tasks that are more easily interrupted when patients need assistance.

3. Are you hiring appropriate staff and training them adequately? Keeping staff turnover low begins with hiring staff members who are a good match for the practice and the position. My article, “Hiring the Right Physician for Your Practice,” [September 2000, FPM, page 41] offers suggestions for matching candidates to practices. Although the article is about hiring physicians, many of the suggestions offered in it, such as conducting thorough reference checks, finding out why a candidate left a previous job and ensuring a candidate's skill set matches the job description, can be used for hiring staff as well.

You should also evaluate your training processes. Find out whether staff members are following standard procedures to accomplish tasks. If they're not, it may point to a problem in the way they were initially trained (or to a problem with the procedure itself, in which case you should certainly invite the staff member to help you improve it). It's critical that adequate time and resources are dedicated to providing proper training and enhancing the skills of new staff members.

If you have a training procedure for receptionists, revisit it and ensure that training was handled properly for the current receptionist. If you don't have a training procedure for this position, now is the time to put one in place. Written training protocols, or manuals, are the most effective training tools and can be maintained and updated when policy changes are made. Not only will a manual help new hires learn their jobs, but it will also force follow-up on decisions and prevent policies from changing daily.

4. Are you offering effective ways for staff to communicate? Rather than looking around the office to ask a question in person, your staff can gain a great deal of efficiency by using an intercom system, voicemail and/or e-mail to communicate. Primary care practices that have implemented e-mail systems frequently tout their success in improving communication.

5. Are staff members supporting each other? Obviously, all staff members need to support each other, but sometimes these efforts deteriorate without anyone realizing it or doing anything to correct it. Your observations may reveal tell-tale signs that staff members are focusing solely on their own work rather than their work as part of the team. The phrase “it's not in my job description” simply won't do. For example, if another staff member sees the receptionist has two patients arriving at the same time, you must ensure that he or she puts the patient first and provides immediate assistance.

Once you've gathered the information from these five questions, sit down with the staff member and discuss your evaluation of the position with him or her. Ask the staff member to respond to the same questions, and then discuss any differences in your answers. This will help you get a clear understanding of the position from the perspective of the employee and management, and it will show your respect for the staff and your desire to build and maintain a solid team.

Solicit feedback

Evaluating each position in your practice can help you spot problem areas you need to work on. But to get the full picture of how staff members view your practice and their position in it, you'll need to hear directly from them. It's important to regularly solicit feedback from your entire staff in one-on-one meetings and staff meetings. This helps keep you constantly informed of what's working, what isn't working, what's changed and where improvements may be needed. It will also show that you value your staff's point of view, which may increase job satisfaction. In addition to this informal method of soliciting staff feedback, it's also helpful to conduct formal feedback solicitation through exit interviews and exit surveys.

Exit interview. When a staff member leaves your practice, you need to find out why. This requires an extensive exit interview with each employee. A staff member will almost always offer some reason for leaving up front, such as he or she was looking for a new challenge, wanted a job closer to home or wanted higher pay. These things may be true, but there are probably some other underlying reasons for his or her departure as well.

To avoid making the employee feel defensive or inadequate, ask questions that invite open dialogue and focus on the practice rather than the employee. For example, don't ask, “What do you think is wrong with the position?” or “Why weren't you able to handle the position?” Instead, ask, “How can we make this job easier for the next employee?” Ask for the employee's help in critiquing his or her former job description and the tasks required for the position. The answers to these questions may give you some insight into how the staff members view practice operations and the management's performance. See “Exit interview questions” for a list of specific questions you can ask employees in an exit interview.

Exit survey. In addition to the exit interview, consider having the departing employee fill out a written exit survey form. Some people find it easier to be frank on paper than in a face-to-face interview. If a written survey is conducted, limit the oral questions to five and the written survey questions to about 10. [See the sample survey.]

A new perspective

Keeping staff turnover low is important. It requires being aware of the current state of the practice work environment, choosing appropriate new hires and providing them with proper training, talking to staff members and solving problems as they emerge. You should strive to provide superior leadership in your practice, keep communication lines open and support the entire staff. Periodically take time to examine the workplace from the employee's perspective, and continually seek to improve it. This will help you create and maintain a place where people want to work and stay!