Here's How Family Physicians Can Hire, Retain Quality Staff

Family physician practices that are adept at hiring and keeping quality employees share one common characteristic -- they create employee-friendly environments that empower staff members to work together as part of a team to deliver excellent health care.

"The main key is having a good place for people to work," says Jennifer Brull, M.D., CEO of Prairie Star Family Practice in Plainville, Kan., a town of about 2,500 residents in the northwestern part of the state. "If you have a good place, you will be able to keep good people," she adds.

The costs associated with staff turnover are well documented -- replacing an employee can cost up to 150 percent of that employee's salary, and when you take into account so-called soft costs, such as lost productivity among supervisors and co-workers during a new hire's training period, costs can climb even higher. Such a high cost for turnover means it's vital that employers work to retain good staff members.

Brull, who started her practice about six years ago, employs three people, but she shares five other employees with two physicians in the same building. And she points out, "We don’t have a lot of turnover."

"One of our front-office employees has been here since our practice began," Brull says. "I have the same nurse I've had since I left residency in 2001."

Not surprisingly, she credits the office environment for the low turnover rates, saying that she likes to empower employees by giving them the ability to identify and solve problems. "We tend to be a very relaxed group of people who get along well," says Brull. "We communicate very informally every day. Formally, we have a staff meeting twice a month that lets people talk about issues and problem-solve."

Easy communication within that relaxed, informal work environment is key to keeping the office running smoothly, Brull notes. "Anyone can come to a provider and say, 'Hey I see this problem, and I think we need to work on this.' They know we will listen to them," she says.

Brull also has nontraditional ways of recognizing staff members' accomplishments. If the front-office staff members meet their quota of payments collected from patients for office visits on a consistent basis, Brull and her colleagues purchase a free day at the local spa for them. She always tries to make sure her employees are having fun. Staff birthdays are celebrated, and, during National Nurses Week, the nurses pick a different theme every day, dressing up to celebrate.

Brull considers all of her employees to be "good friends," which can complicate things if a problem arises. "You have to shift out of the friend mode to the boss mode," she says. But she adds, "I really enjoy being friends with my employees. I would say the benefits overwhelmingly outweigh the pitfalls."

One of the keys, Brull says, is to provide an environment that is supportive and fun with a good structure. "It is kind of like being a parent," she says. "You have to have a good structure and good discipline."

On the other hand, she says, "You have to be consistent. You can’t make a rule one day and change it the next."

George Shannon, M.D., a physician partner with Horizon Diagnostics in Columbus, Ga., says he's found that a simple "Thank you for doing a good job" at the end of the working day is a strong motivator, even more important than benefits or salary for many employees.

"Salary doesn’t hurt, cash bonuses don’t hurt," says Shannon. "But the reality of it is telling people 'Thank you' is oftentimes a very powerful tool."

Horizon Diagnostics comprises 15 primary care physicians, one gastroenterologist, two general surgeons and a support staff of about 100 employees. The practice, run out of five sites in Columbus, has been "in tune to staff needs and staff morale" since its inception six years ago, Shannon says. It has, however, established several different mechanisms to promote a staff-friendly environment.

"The difference between a pat on the back and a kick in the butt is only 27 inches," says Shannon. "If you give your employees encouragement and give them correction and treat people fairly, it is very seldom they will not treat you fairly back."

The practice gives every employee a certificate during an all-staff party at the end of the year to recognize their work, Shannon explains, pointing out that "happy employees take good care of patients."

"You have to recognize what the goal of the organization is," he says. "And the goal of our organization is to give good, quality patient care. You cannot do that without having excellent staff."

Shannon notes, "We have had staff who have left us and gone to work for other physician offices. They call us two days later and ask, 'Can I come back?' because the environment in other physician offices is not a friendly environment and they do not feel their work is appreciated."

In addition, at the end of the year, if the practice comes in under budget, the leftover funds are divided among the physician partners and staff members. The bonuses are prorated, based on time spent with the company, providing another incentive for staff to stay.

"Our folks -- the ones who have stayed with us -- have gotten four-figure bonuses at the end of the year," Shannon says. "For my purposes, if we can come in under budget, that saves me money."

Horizon Diagnostics also buys back employee sick leave at the end of the year, paying employees for the sick days they do not use. "It is called a wellness bonus," says Shannon. "We buy it back at an accelerated rate." The wellness bonus serves as a powerful incentive to utilize sick time appropriately, he adds.

In addition, Shannon says, it is important to establish standard policies and procedures to ensure employees are treated fairly and consistently. "We deal with problems as they are problems; we don’t let things smoke," he says. "If you have a disruptive employee, you give them a verbal warning for the first offense, a written warning for the second offense and the third time, you terminate."

The practice's policy manual spells out transgressions that require due process before termination and behaviors, such as stealing or physical abuse, that result in automatic dismissal.

According to one expert, Shannon and Brull may have harnessed one of the most basic but powerful human emotions -- the need to feel a sense of pride and meaning in one’s work.

"Most of us don’t want to go off to work in the morning and say to our spouse, 'Oh, I am going to do more meaningless stuff today, and I hope you have an absurd day too, honey,'" says consultant John Schuster, president of the Schuster Kane Alliance, a 25-year-old, Kansas City, Mo.-based leadership and development firm that conducts coaching and training workshops for private-sector companies.

Employees have a "deep drive for meaning," and thank yous and other acknowledgements create meaning, Schuster says.

A good employer sets direction and provides good feedback, removing barriers that might prevent employees from accomplishing work they think is worthwhile, he says. "A good day for most employees is getting important work done -- not having to fight bureaucracy and bad procedures and bad computers. Most people want to do a good job."

A good employer also listens and incorporates employee ideas, Schuster says. "(Employers') ideas are often quite good, but you will never really have a high-functioning office until you tap your employees' imaginations."

Employees, he stresses, "support what they help create. If you have a change in procedures, involve the people who are going to execute the change in the process. Don't lay it on them with a technical person who comes in and sells you a new deal and says, 'Here you go.'"

Naturally, employers try to hire people whose talents fit the job. And they strive to give employees a strong sense that their jobs have meaning. An employer, for example, should never define the receptionist’s job as a technical position; a true receptionist sets the tone for the front of the office, Schuster says.

"You give them a bigger responsibility, which is, 'You are responsible for the emotional force field of that front of the office,'" he explains. "That has two things in it: friendliness and competency. Patients feel warmly accepted and feel they are going to get problems taken care of because the receptionist knows what is going on."

Schuster is a firm believer in conducting background checks on prospective employees. He also is a strong proponent of doing exit interviews with departing employees. "People tend to tell the truth when they are leaving," he says.

Employees leave jobs for a variety of reasons: a lack of growth opportunities, frustration with the work or an emotional disconnect resulting from a feeling of no longer belonging to the team, says Schuster. Even if the employer does everything right, there are situations or environments that make it difficult to retain staff.

Virgilio Licona, M.D., of Fort Lupton, Colo., associate medical director of Salud Family Health Centers, says it is hard for Salud to keep physicians and support staff because the centers struggle to compete financially with the private sector. Salud employs 43 physicians and 20 mid-level providers, including physician assistants and nurse practitioners, who work at nine sites that stretch over a 300-mile radius.

"We are a not-for-profit organization, and so our salaries are not always as competitive as the private sector," Licona says. As a result, some staff members work at the community health centers to acquire experience before moving on.

Licona, who also is a member of the AAFP Board of Directors, says he expects and even welcomes some staff turnover, adhering to an 80/20 rule -- 80 percent staff retention and 20 percent turnover. He focuses on limiting staff turnover in key positions, however. Salud, for example, gives medical assistants an educational allowance of $250 a year to advance their personal careers.

That simple act means a lot, according to Licona. "It is not the amount of money that we give, but the idea that we value them and allow them to decide where they think they would like to improve," he says.

Salud also opened a computer training center and a medical laboratory training center for employees last year. In addition, Salud holds an annual employee picnic that focuses on team building and friendly interoffice competition to promote a sense of cohesiveness.

"We are part of a large system of care, and although we have different roles, different functions and different clinics to work in, we are all part of the same organization that provides high-quality care to the patients we take care of," says Licona.

"Everyone on the team has a role to play in making you collectively successful in providing health care to your patient population. If you appreciate everyone for the role they play, they are going to feel they are valued," he says.