Terminating An Employee

It is never an easy task to terminate an employee.  After sifting through resumes, interviewing, and finally choosing a candidate, it is so frustrating to find that your employee choice was not what you expected.
In this economy, you will have been inundated with hundreds of resumes for every posted job.  Although you were certain to ask for specific skills in your posting, you will find that you receive resumes from persons in all walks of life and more times than not, these individuals lack the skills that you are seeking.

When you finally find what you think is the right person to fit your job description, you may discover after a period of time that it wasn't the right person at all.   People can misrepresent their skills and experience levels, which is why it is always necessary to perform a thorough background check.  Often times you will find that your candidate has been employed in an office not far from your own and you may know the office manager or human resources manager, where the candidate was employed.  You should have a specific task list ready prior to your background check and you may feel free to ask if your candidate was proficient at the tasks you require.  You may also ask whether the former employer would consider re-hire of this employee, but you may not delve into the personal details of their lives.

Many on-line companies offer inexpensive background checks that will detail any prior undesirable history and you may feel free to use these tools as long as you have the prospective employees understanding and signature on file allowing you to investigate their past.   Should your office require drug testing, you will want to use an independent laboratory and send only those candidates that you are considering seriously.

As previously discussed, you should have a standard training schedule and your new employee should be able to perform certain tasks independently, within an expected time frame.  In addition to becoming proficient at their new job description, your new hire must show that they are able and willing to work well with their colleagues and show courtesy and respect to both the patients and their fellow workers.

Despite your best efforts to integrate your new hire into your work force, they may fall short of your expectations and you may discover that this individual is not suited to your organization.  In this case, your most important task is to document each instance where the employee has fallen short of expectations.  Your report should be in writing and you should meet with the employee and explain how they have not met your expectations and obtain their signature post meeting.   A careful record of problems will avoid any labor issues in the future should you decide to terminate this employee.  

You may want to consider whether or not an employee who does not show promise for their hired job description may be able to make a good fit elsewhere in your organization.  Perhaps they have show a particular talent in working with patients, or they are not great with patients, but are highly skilled at obtaining referrals or pre-certifications.  Since they have already become familiar with your office and your other employees, it will save you additional training.  Alert the employee to the possibility that you are considering them for an alternative position and should this new position hold a lower salary or benefit level, make sure they have a clear understanding of the ramifications of a lateral move and agree to it in writing.  Assure the employe that this change does not represent a demotion, but an attempt to keep them employed at a job where their particular skills may be better represented.

If all else fails and you must terminate the employee, you would be wise to provide them with copies of your evaluations and discuss their positive skills and suggest that they may be better suited to a different type of employment.  Unless there has been a clear cut violation of the policies and procedures in your employee handbook, or instances of behavior that you have stated hold zero tolerance, it is never necessary to treat a terminated employee with anything less than courtesy and respect.

It is never easy for someone to lose a job and the employee often feels humiliated and deeply hurt that they could not meet the practice expectations.  Your purpose is not to demean any individual but to express appreciation for their efforts and to suggest that their particular skill set is not suited to your office needs.  Make sure that you provide your employee with an exit interview and information necessary to obtain Cobra coverage, if your office has provided health insurance or other benefits that the employee may want to continue to receive.  In cases, where immediate dismissal is not an issue, you will want to give the employee some notice prior to their last day of work.  You may want to restrict their computer access during their last days or even simplify their job description.  Assure them that they will be paid, according to the payroll schedule for any last days of work.  Do not hold paychecks hostage, even if your employee did not respond well to their dismissal or chose not to finish out their last days.

Remember the way you treat your former employees reflects as strongly on the practice as your treatment of your present ones.   You will find that even terminated employees will be gracious when it comes to the practice reputation if you treat them with a sense of genuine loss and disappointment that their skills did not match your needs. 

Prescription Drugs - Panacea or Tragedy

Most patients in this country feel that if they schedule a sick visit with their physician and they don't come home with a prescription, then they really weren't sick.  Those white sheets and the pills that come from the local pharmacy are proof positive that going to the doctor was a wise move.  We are a pill freak culture and the drug companies that supply us with our daily doses are laughing all the way to the bank.

Trillions of dollars are made each year by the pharmaceutical companies and there is little reason to wonder why so many drugs are rushed to market each year to keep the cash flowing.  After drugs such as Avandia prove to be fatal to many patients, we are often left to wonder who is overseeing drug trials and how are such good results published with such horrible consequences?   I attended elementary school with a little girl who was missing an arm as a result of Thalidomide, my daughter-in laws cousin died from a prescription heartburn medication, and I saw the effects of Avandia on my own mother.

One answer lies in the fact that the American public has an insatiable demand for immediate gratification.  We feel pain and expect immediate relief, without giving much consideration to the consequences of the medication that we ingest so mindlessly.  Over the years, I have consulted with two physical medicine and rehabilitation practices and during my years there, the staff came to realize just how many drug seeking patients are floating around in the general population.  These individuals may have started out with a real injury or some form of chronic pain.  Instead of seeking some alternative relief after initial doses of medications did not ease their pain, they move instead to a chronic cycle of pills and more pills, using any and all methods to obtain their meds.  Drug seeking patients may move from doctor to doctor and try to fill scripts at different pharmacies to avoid detection.  Luckily, the larger chain pharmacies are now alerting each other when patients try to fill multiple scripts for narcotics.  They will also act to notify the physicians in question, trying to put a stop to what could be a life threatening situation.

More PM&R practices are now using trigger point injections, physical therapy and even acupuncture rather than medication to treat acute and chronic pain.  They are examining the patient's lifestyle, work and home environment and suggesting exercise and ergonomic strategies that will promote a healthier lifestyle where the patient is less prone to injury or exacerbation of pain.  Patient's are often grateful for a more homeopathic approach to their complaints and find that by making small changes in their daily activities, they can become pain free without medication and its associated risks.

Type II diabetic patient should always be encouraged to change their diet and exercise routines before they become one of the millions of Americans whose blood sugar levels are dependent on medication.   The same holds true for those of us who suffer from high cholesterol.  There are some homeopathic remedies, such are red yeast rice, which can lower cholesterol without the side effects of most statins and I have seen cardiologists recommend these over the counter drugs to patients who could not tolerate or refused statin treatment.

It is important for our doctors to adequately explain to patients that viral syndromes do not respond to antibiotic treatment so it is not always necessary to receive medication for a cold or sore throat.  In cases, where serious illness has been ruled out, patients with such problems as chronic headaches or other chronic pain, should be encouraged to seek help from a homeopathic provider before embarking on a future where medication is the only way to alleviate pain.

We are starting to see some progress towards a blend of allopathic and homeopathic treatments in a number of our medical communities.  Physicians and Chiropractors are often working together to treat some chronic pain patients, and many doctors are now embracing the use of acupuncture and herbal therapies with their patients.

All of us are grateful for the extraordinary drugs and vaccines that have kept us healthy and safe from diseases, but we must admit that some of the drugs that come to market may have tragic consequences, and that no drug is without its effect on the human body.  
 

The Insurance Game

Month after month, we, the faithful, pay our insurance premiums or face the probability that we will be denied health care coverage if we should become ill.  All over our country, those who have lost their jobs, or fell on difficult times found that their children could no longer visit their pediatrician, husbands and wives pray nightly that serious illness will not land on their doorstep.

Even those of us lucky enough to have current coverage have to sweat it out every time we need a test or procedure, the recommendation of our physicians not good enough to guarantee us diagnosis and treatment, unless our carriers feel that we should be privileged enough to get a positive nod.

Our physicians wait patiently for reimbursement for services, in a cat and mouse game of how long can we keep our money in the bank before we need to release a check for payment.  How many notes will we request?  Letters of medical necessity?  People are no sicker now than they were forty years ago, when the physician would send a hand written note to the insurance giants and received a check, most times for close to the full amount billed.  How did our physicians and our patients lose the ability to gain assured treatment ?  Who are these guys and what's their problem?

Certainly there is no greater rip-off in the American way of life than car insurance.  We pay month after month for a service we don't use and then get charged an even higher fee if, heaven forbid, we do make a claim.  Think about it for a minute.  Every month, a charge for nothing....  I could understand if our premiums payed for oil changes, or new tires, or a tune-up every six months, but literally we send a check to a strange location for NO service.  Only in America!!!!!  

I propose that for every year we do not make a claim, our total premium, minus a small administrative fee should be refunded in full.  You say you want to boost the economy?  What would be better than getting a check every year on December 31st for driving safely?  Imagine how much of this money would serve as a stimulus to the economy.   Perhaps, instead of billions of dollars in profits each year, the insurance giants would only make millions.  What a damn shame !!!!

It wouldn't be a bad idea to make the same transition with health insurance.  Instead of forming more ACO groups, whose sole purpose is to save money by denying treatment, let's reward our patients for making an effort towards preventative medicine.   No emergency room visits in a year would guarantee you a refund on your yearly premium.  Compliance with testing and physician recommendations would give you another small bonus.  Enrolling in an exercise program - more cash....  Soon, we would have a society where individuals sought treatment to maintain health and prevent illness, rather than using their local emergency room as a refuge for a sore throat because in many cases, emergency care is covered in full.

We expect the American public to pick up the slack for every shortfall in our country and to pretend that they don't have the foggiest notion of the profits made by the insurance companies, year after year.  We expect physicians to render excellence in health care, when their reimbursements are cut again and again.
Right now, we pay a ridiculous amount for gas and home heating oil, but I can assure you that the big shots at Exxon or Mobil are not going hungry to be able to afford their prescription medicine.

In the years to come, we will lose many good physicians and our future students will avoid the study of medicine like the plague.  It's time we stopped dreaming and expecting the American middle class to keep doling out dollars for zero services. 

Women and Health Care

Over the past ten years, we have seen extensive changes in the healthcare industry and those of us involved in dealing with these changes often channel our energy into making sure that our office is in compliance with everything new that comes our way.   We pride ourselves on implementing the details that will make our office state of the art and dedicate ourselves to the difficult challenges that we need to follow carefully.

So many discussions that I have seen recently come from my colleagues who are interested in assuring that medical practices meet today's tough standards.  The discussions that I have seen my brilliant colleagues promote are no doubt helpful and necessary, but sometimes it seems as if we are talking about the best way to organize and run an empty location.  In keeping with this idea, I would like to discuss the disparity that still exists in the diagnosis and treatment of men and women.

Five years ago, I was diagnosed with Graves disease.  For those who are not aware, Graves is basically auto-immune hyperthyroid disease and can pose serious health risks if not treated, or not treated properly.  I was lucky enough to be diagnosed and treated early in the progression of the disease and finally received treatment with radioactive iodine in the hopes of alleviating my symptoms.  This treatment may eventually lead to hypothyroidism and I will need to be treated with other medications to keep me in a normal range.

Hyperthyroidism, like many thyroid disorders can have a neuro-psychological component, which may include anxiety, depression, rapid heart rate and in some cases can manifest itself as bi-polar disorder.
Some Grave's patients may experience these feelings even if their ranges are just slightly abnormal and others may have blood results that are off the charts and remain unaware of the disease until they suffer some serious health risks.

My experiences with Graves were the first time I noticed how difficult it can be for physicians to recognize and treat the components of disease that are not strictly physical.   Indeed, at times over the past five years I felt like one of Freud's garden variety neurotics anytime I would express a symptom that was outside the physician's realm of expertise.   If I expressed the fact that I felt more anxious than usual, the physician would state: "People get anxious for all kinds of reasons!"  It got so bad, that I found myself searching the internet looking for research that would convince me that I was not neurotic or crazy.   I looked at message boards where Grave's patients discussed their symptoms and noted that these patients were meeting with the same denial from their physicians.  I finally decided to seek help from a female doctor who assured me that the symptoms that I was experiencing were all part of the Grave's syndrome.

As a younger woman, I was treated by the same family physician who treated my parents and grandparents.  He knew our entire family history, including the state of our mental as well as physical health and was able to diagnosis and provide treatment that included both our physical symptoms as well as our genetic pre-disposition to certain diseases.  That time is long past and it is unfortunate that medical care has become so specialized and so limited that patient treatment is no longer a consideration of the individual as a whole, but rather Part A and Part B and all the other parts that make us who we are demand that we see an entire arsenal of doctors to keep ourselves healthy and happy.

I have accompanied my husband on many of his doctor visits and have noted the clear difference in the way physicians treat his complaints.  They seem to listen more carefully and prescribe treatment for the slightest of his complaints.  Since I have worked in this industry for so long, I know many of these physicians and even this fact has not made much of a difference.  I am not alone in this feeling and have found that many of the women I know make it a priority to see a female physician for all their health care needs.

In order for us to provide our patients with excellence in health care as we move forward into the future, we need to see our patients not merely as a symptom, but as an entire individual who may need help with both the physical and psychological implications of disease.  A quick family history will not help us in this goal.  We need to spend more time listening to our patients and to assure that we do not merely discharge them to another provider if we are outside our comfort zone.

Missing Billing Sheets

Despite the push forward to electronic medical records, many physicians in my New York area are still using the old chart system.  Some physicians are not even ready to e-prescribe and have told me that when the penalty matches the cost of the system, they will think about spending the money to update and participate.

I have implemented my "Daily Data Sheet" in the routine of many practices.  It is available in an installment of this blog and has succeeded in increasing the amount of daily co-payments that are collected and has tried to assure that the amount of billing sheets matches the amount of patients that are logged in each day after they sign in for services.  The purpose of the data sheet is two-fold.  One is to prompt the front desk or check-in to collect the correct co-payment amount for each purpose.  The second is to assure that each patient that signs in has an appropriate encounter for his or her visit.  Herein may lie the rub!

Some physicians do not think it is a priority to finish their billing sheets each day and in some respects you can hardly blame them.  With the cuts in reimbursements, more patient visits are required to keep the financial aspect of the practice on track.  These means more patients and less hours in a normal work day.   Secondly, the insurance companies are requesting patients notes for almost everything and this means that a short progress note, made in the chart, is no longer viable, even for the quickest of return visits.  Consequently, for each minute that the doctor is dictating his patient notes, patients wait in the exam room or if the physician jots a quick progress note, with the intention of finishing his dictation after business hours, he may find himself without any other life but the one he pursues in the office.

This can present a serious problem, especially if the practice is farming its billing out to a service.  The daily package often goes out incomplete.  The physician reasons that if the majority of his claims go out complete, than he will catch up in a few days and this won't present a serious problem.  Wrong !!!!
Your daily billing package should always go out complete or you will find yourself mired in paperwork with no end in sight.   Your billing company will be contacting you daily or weekly to find out if the patient listed on the data sheet was seen and if so, where is the encounter ?   If these issues are not immediately addressed, you will receive the same request from the billing company over and over again, and find your office pulling the same charts, copying the same letters, and sending the same notes again and again, wasting valuable time.

Saving five charts today means ten charts tomorrow and so on and so on, until the doctor is literally buried in unfinished work.  An incomplete billing package means that encounters from June will be completed in August and this will have a cumulative effect on your daily revenue.

What's the solution?  Short of taking charts home on the weekends, which many physicians do and which is not a good practice, or in keeping with HIPAA policies, the answer is to make time to finish all of your dictation the same day as you see the patients.   Regardless of how you prepare chart notes, the doctor always knows what services he renders to each patient.  Therefore, a completed billing sheet should accompany each patient exit.  If notes are necessary, you can jot a quick progress note in the chart and mark the outside of the chart with a sticky note that will alert the physician that he has not dictated for this particular patient.  For those truly fanatical physicians, you can make a copy of the encounter and mark it with a D- for dictation and place it on the outside of the chart, removing and disposing of it when the dictation is completed.

I have seen doctors keep a record of patient visits on the outside cover of the chart, noting special procedures performed.  You could initial this medical log sheet every time you dictate on a patient and be assured that all work is completed.  Those charts without an initial complete, can be placed to the side and dictated at a more convenient time in the physicians schedule.  This outer chart logging of procedures also reminds the doctor when a patient needs a follow up test or procedure, without them having to explore all the chart pages individually.  This method also serves to make life easier when calling patients to remind them that they need a return visit.

At the end of each day of patient appointments, the number of patients seen should equal the number of billing sheets that are turned over to be processed.  While this may seem so old fashioned to those who are already entrenched in the spirit of the electronic world, it is essential to those physicians who have not yet made the leap.  While so many doctors get comfortable in their old ways of doing business, the business world of medicine is leaving them behind.  Whatever it takes to get the job accomplished and to prevent the duplication of tasks is mandatory if your practice is going to survive the health care changes that are here now and in the future.

What is the Future of Nursing?

So many nurses are expressing dissatisfaction with their field today that many of them are making the quickest leap possible away from the bedside and into administration.  Consequently, patient satisfaction scores are going down , especially in our city hospitals and many patients are scared to enter today's hospital systems unless they have a patient advocate, a family member or friend, to speak for them and to assure that their care is not sub-par.

Our city hospitals are overburdened by too many patients and too little qualified staff.  There is a large immigrant population in our hospitals today and these patients often bring with them their own set of cultural mores and sense of entitlement.  Indeed, many of today's nurses are foreign graduates as well and we face serious issues when the standards of training from country to country vary to the extreme.  In many cases we are getting nurses who do not possess the standard of care skills that are basic to United States nursing and this can have terrible, and sometimes tragic results for their patients.  Nursing supervisors and directors often feel the burden of these issues.  They expect their RN's to be well trained and educated and are shocked to find that the patients are suffering when the basic standards are not adhered to.

There may also be language barriers that prevent a sense of communication between the nurse and the patient, which also places their care in jeopardy.   Nursing directors are often throwing up their hands in frustration and abandoning their reports and paperwork to make sure that bedside care is administered in a proper fashion.   In a busy environment, where nurses are in short supply, it is not that easy to call upon your department of nursing education and have your nurses re-trained in the skills and procedures that are lacking when you have one nurse for sometimes twenty to thirty patients.   Couple that with our present electronic age and you may now find your nurses spending much of their time on cell phones, and text messages.  

I don't know why, but there seems to be a general lack of apathy that exists in the workforce today.  Years ago, the worst thing that could happen to an employee was to have the feeling that they were not up to the tasks required of them.  People seemed to take more pride in their work and looked for ways to increase their own productivity and skills.  Much of today's work force exists from check to check.  They have child care issues, and family issues, and lack of skills issues, that make them more of a burden on the system than a correction.  Couple that with a population that is more than ever, uninsured or under insured and the city hospital of today, finds itself in serious financial hot water.

Thirty years ago when my children were born, the hospital where I gave birth was immaculate.  The floors were spit polished constantly, the bathroom fixtures gleamed, and the nurses were all is their starched whites, shined white shoes and caps, no less.  The food was glorious, you rang your buzzer and someone was at your bedside in a flash, and they took your vitals in what seemed to be fifteen minute intervals for two full days.   A few years ago, my father-in law had cancer surgery in the same hospital.  The place was filthy, the bathrooms disgusting, and you couldn't tell the nursing staff from the maintenance staff were it not for the name tags.  No one came to take him to the bathroom, physical therapy never showed, he did not get meals for two days, and he died in a literal hell hole of incompetence and apathy.

It's almost impossible to find the cure-all for these problems, but when the time comes, where hospitals are reimbursed for patient satisfaction, you are going to find that many of them will simply have to close their doors.  How ridiculous is it that we are making doctors spend hundreds of thousands of dollars for electronic gadgets to standardize medical care, while we are allowing our sickest patients to wallow in an environment where their lives depend on so many who are unqualified to meet the challenges that medicine demands.   We should insist that the staff of our hospitals are trained with a uniform method of care, that our nurses know the expectations that we place on them and more important that they are qualified to meet these expectations.   We are living in an age where there will be a literal explosion of patients who are entering their twilight years and will become by their sheer numbers, the highest demand on an unprepared health care system.   Isn't it about time we started to get prepared?

Is Your Work Force Still Viable?

Single practice physicians are the most vulnerable to the curse of "The Corrupted Employee."   Often these docs have practiced in a framework that is somewhat disorganized and without set policies and procedures for the performance of daily tasks.  In addition, the physician may be prone to cancel office hours or reschedule his patients based on his or her personal demands.  Vacations and sick days happen and while the staff needs to be paid and to work a sufficient number of hours to assure that their paychecks are viable, the office sometimes becomes a free for all.

When the cat's away, the mice will play is an unfortunate fact of life that you can count on if your staff is left without proper supervision.  Many senior staffers fall into the role of office managers, often without the skill set or authority to enforce the rules of the day when the doctor is not in the office.  The greater freedoms that are allowed, the more the rules will be broken, and many times they are broken to the point that they really cannot be repaired.

I have seen situations where staff clocks in, then goes to the deli for something to eat and drink, then sits for forty minutes, eating and drinking.  These are the first employees who will claim,"I don't have time," when you suddenly expect them to follow any new policy.  You will find paperwork in drawers, files or notes everywhere, and a general lack of accountability in these offices.  What becomes the norm when the physician is away, then becomes more the norm when he or she is in the office.

You can try your best to change these situations, unfortunately, many times to no avail.  There comes a point when even the greatest consultant or practice manager can no longer inspire the corrupted employee.   Doing as little as possible becomes the new job description and employees resent having to change their style and attitude.  

You should of course do your best to rectify this type of situation, but it is not beyond the realm of possibility that cleaning house becomes your only option.  If you have promoted a practice without a daily routine or reasonable expectations, you may not be able to salvage your present staff.  It is essential that employees have a job description that keeps them busy for their entire day.  They must complete a number of tasks and have an hour by hour routine, day after day, that promotes organization.  If you have employees with too much time on their hands, then you have too many employees.

Work is a privilege and in the current economic situation, there are people that would wait outside your office door for the chance to earn a paycheck each week.  If your present employees are not meeting your expectations, then it may be time to train a new set of employees and expect that they will be grateful for the opportunity to work and be productive each day.

Don't fall into a pattern of laziness where all your employees are still on the job when you are away.  Paying people to do nothing is ridiculous as well as a tremendous strain on your payroll revenue.  If you are away on vacation, or need to cancel hours for the day, make sure you only keep a skeleton crew in the office to answer the phone and make future appointments.  You will see how fast your employees want to become essential, whether or not you are there.

You cannot change from an easy breezy individual who lacks the ability to discipline your staff to someone who now wants total compliance to the rules that were never enforced in the past.  Change takes time and effort and change must first begin with the physician.  Put in the effort to speak to your staff and to tell them what you expect and the changes you want to put into play.   Make sure that the principles of change- the desire for organization and assured revenue - start first with you.

If after a time, you find your staff cannot make the proposed changes then you must take steps to replace these individuals with others that are vested in your practice mission statement and goals for the future.