Most medical practices are multidisciplinary requiring the coordinated efforts of many highly skilled professionals. The precise relationship of management to the staff varies dramatically over a variety of practice settings, but all have several key factors in common.

When You Have Your Own House, You Can Make the Rules

This is a simple concept, but perhaps an unfamiliar one to the newly minted physician who, despite years of training, has yet to own his own home. Your ownership of the practice improves the quality of your staff by making them entirely  accountable to you as a manager. Situations in which there is no ownership stake by the physician group create inefficiencies in employee motivation by requiring the efforts of middle managers who contribute little to the bottom line of an efficient medical practice.

Staffing Soup to Nuts

All medical practices require a competent receptionist and front office staff. Their duties center on greeting patients and families, answering phone calls, making appointments, and attending to the operational concerns of patients. Often such individuals can serve a role in billing, chart completion, quality assurance, and secretarial duties, which relieve higher-paid professional staff to devote more of their time to their knowledge-intensive duties. The receptionist represents the front line of the patient’s experience with your practice, so it is critical that these individuals are able to be empathetic to the patient’s plight and be willing to serve an emotionally supportive role when needed throughout the day.

Good nursing staff is key to attending to the day-to-day clinical needs of your patients. These nurses hold an extremely important position within a practice because they serve as the patient’s link between the familiar outpatient medical environment of a waiting room and the medical staff There is no benchmark requirement for such individuals beyond the need for at least one at all times. The patient mix, the clinician demand, and the integration of multiple specialties all affect the relative need for skilled nursing.

Other staff include dedicated billing staff, lab personnel or specialized ancillary staff depending on the type of medical office.

Salaries

Determination of salary is a complex calculation and very variable by practice. It is important to consult salary surveys specific to the type of medical practice before hiring staff.

Hiring and Firing

Some staff can be considered hourly employees while others are salaried. In order to be considered “exempt” staff who are salaried, the following criteria must be met:

• Minimum $170 per week salary
• Advanced work knowledge (certified, licensed) and independent judgment
• No more than twenty hours/week on nonprofessional activities
• Doctors, RNs, certified technicians, physician’s assistants, and physicists fulfill this description.

Of note, salaried employees are not generally entitled to overtime; this is an important consideration for some clinics where demand for therapy services can vary dramatically over the course of a calendar year.

At-Will Employment

At-will employment means that unless there is a contract governing the duration of employment, an employee or employer can terminate their relationship at any time without taking on liability. This tenet does not apply to employees who are unionized or who are party to a collective bargaining agreement. From a management perspective (and potentially an employee’s), at-will employment is the preferred relationship; it allows the most leeway to respond to the needs of each party over time.

Employment Laws and References

• Civil Rights Act of 1964, Title VII: Does not allow discrimination based upon race, color, religion, national origin, sex, and pregnancy.
• Equal Employment Opportunity Commission (EEOC): The EEOC is a federal agency whose mandate is to end discrimination in the workplace. The EEOC offers a detailed Web site with numerous resources at the EEOC website.
• Age Discrimination in Employment Act of 1967 (ADEA): The EEOC offers the entire congressional act on its Web site. The act protects the employment rights of people over age forty and has been amended several times since its adoption.
• American Disabilities Act of 1990 (ADA): The ADA of 1990 prohibits discrimination based upon an employee’s disability. For reference, more information is available on the ADA Web site.
• Fair Labor Standards Act of 1938 (FLSA): FLSA established the minimum wage, time and a half for overtime employment, and limited child labor in the work- place. The U.S. Department of Labor provides an extensive Web-based resource at http://www.dol.gov/compliance/laws/comp-flsa.htm.
• Equal Pay Act of 1963: The Equal Pay Act established equal pay for each gender for equal work. The EEOC offers a helpful link to clarify the application of this law at http://www.eeoc.gov/policy/epa.html.
• Military Personnel: Military personnel are protected by the Uniformed Services Employment and Reemployment Rights Act (USERRA), the Public Health Security and Bioterrorism Response Act of 2002, and the Vietnam Era Veterans’ Readjustment Assistance Act (VEVRAA). These laws protect a service person’s right to return to the labor market following military service or being called to duty to respond to a national emergency. The U.S. Department of Labor provides numerous Web-based resources at http://www.dol.gov/compliance/topics/hiring-vets.htm.
• Sexual Orientation: Several states have passed laws that protect employees from discrimination based upon sexual orientation: California, Colorado, Connecticut, Hawaii, Iowa, Illinois, Maine, Maryland, Massachusetts, Minnesota, New Jersey, Nevada, New Hampshire, New Mexico, New York, Oregon, Rhode Island, Vermont, Washington, and Wisconsin. There are no federal protections for such employees currently.
• Family and Medical Leave Act of 1993: Grants that employers must grant an employee a total of twelve weeks of unpaid leave during a twelve-month period for: the birth and care of a newborn child, care of an immediate family member with a serious health condition, in the instance that an employee has a serious illness, or the care of an adoptee or foster child. The U.S. Department of Labor provides a detailed interpretation of the law and numerous resources at http://www.dol.gov/esa/whd/fmla.
• Occupational Safety and Health Act of 1970 (OSHA): OSHA ensures health and safety at the workplace. The Occupational Safety and Health Administration is an agency of the Department of Labor and has a broad mandate and powers to perform this function. Additional information can be found on the agency’s Web site.
• Nuclear Regulatory Commission (NRC): The NRC regulates the use of nuclear medical isotopes through Title 10, Part 10, of the Code of Federal Regulations. The NRC regulates the following: dose limits for radiation workers and the public, exposure limits for individual radionuclides, monitoring and labeling radioactive materials, posting signs in and around radiation areas, reporting the theft or loss of radioactive material, and penalties for not complying with NRC regulations. Thirty-five states have entered agreements with the NRC to formulate and enforce radioisotope regulations within their own borders (so-called “agreement states”). For a more complete description of the NRC’s man-date within the workplace, refer to the NRC website.
• Workmen’s Compensation: Also known as worker’s compensation, this is a form of employment insurance administered by individual states to ensure that workers injured on the job will have medical care for their injuries and often remediation of lost wages. Every state has such a system, and one should check with his state government for details regarding the administration of such a plan. The worker’s compensation Web site of the state of Florida, for instance, offers links to all other state plans at http://www.fldfs.com/wc/otherlinks.html.

Employee Agreement

Employee and employer relations need to be carefully managed through a well-crafted employment agreement. The agreement should, at minimum, have the following elements:

• A detailed description of the position and its duties
• Salary, bonus, inflation adjustments, and benefits
• Dispute resolution apparatus such as arbitration in the event of a disagreement
• Length of the agreement
• The definition of causes that will manifest in termination of employment
• Clauses that limit the ability of the employee to disseminate trade secrets
• Vacation arrangements, expense accounts
• Situations when the agreement terminates for reasons other than employee performance