Judy Capko is a health care consultant and the author of "Secrets of the Best Run Practices."

Judy Capko

"Problem" employees can sometimes be misunderstood thoroughbreds. They have the best interests of the practice in mind, but may need more clarity or more support to do their best. Often, a thoroughbred's complaints can illuminate trouble spots that are brewing with the practice-issues that your team's easygoing workhorses are suffering without complaint, but that really should be fixed. Sometimes the thoroughbred's extra sensitivity to minor workflow issues is a gift to the practice that allows management to head off problems while they're still minor. 

Is your complainer a thoroughbred in disguise? The type of complaints you're hearing provides a clue. Recently, we worked with a practice with a "problem" employee who was driving the practice manager crazy with her "issues" and requests. She was frustrated that the office network was frequently down, wanted headsets for her and the other receptionists, and was repeatedly offended by the shoddy work of the practice's cleaning service. Instead of being annoyed with these requests, though, the manager should have been listening. Every one of the employee's complaints involved an issue that would diminish productivity, adversely affect patient service, and could explode into a bigger problem if not addressed. 

 For thoroughbreds and workhorses alike, clarity of roles and a clear path to providing feedback to management are essential to top performance. 

A lack of clearly defined staff roles is one of the most common operational problems we see in urology practices. Knowing exactly what is required to do a good job is essential for employee morale, especially for highly motivated or perfectionistic thoroughbreds. Clarity of roles is also essential to creating accountability-to ensure everything that needs to get done gets done. If you've been repeatedly bothered by a squeaky wheel or wheels, be sure your own internal communication and HR systems are up to snuff. 

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Every urology practice faces this situation eventually: a difficult employee who demands disproportionate time and attention from management.

Your high-maintenance urology office staffer: Worth the hassle?

The essence of cloud computing is that data are stored on remote servers and accessed via the Internet, rather than maintained on local computers inside the practice. Storing data remotely allows for access from anywhere using the Internet, so, for example, a cloud-based EMR allows urologists in your practice to access and update charts from home or on the road using a smartphone or tablet. 

Moving a processing-intensive task like medical billing to a cloud-based provider such as Kareo, CareCloud, or athenahealth can be an efficient solution for many reasons, and is often a good first step for a practice considering utilizing the cloud. 

Perhaps the most obvious benefit is that even though the software is complex and powerful, such systems generally don't require in-house support. Cloud-based software is accessed remotely via a browser or downloaded interface, usually doesn't require an investment in better or faster computers to get started, and requires very little (if any) effort to install. Updates are usually automatic, so there's no need for an IT person to upgrade computers separately or maintain control of versions across your team's PCs. Adding or subtracting users is generally just a matter of one more or one less monthly fee. 

Cloud-based systems can also be accessed from anywhere you can connect to the Internet, so even if your office network goes down, your billing manager can submit claims from a home computer or a laptop off site. (A 4G-enabled tablet, accessing the Internet over the cellular system, would take this convenience and redundancy a step further.) 

Even if you're using a third-party billing service, a cloud-based billing system can be a big plus. If you decide to switch providers down the road, you can usually find a new service or independent contractor that uses the same system easily through the vendor's online community. In addition, an SaaS-based system that your team already uses in-house for practice management and insurance verification would smooth the process of bringing the billing piece in-house if you decided to do so in the future. 

Running your own EMR server within your practice requires significant resources and, often, dedicated IT support. There are significant "hidden" costs, too, namely energy and office space. And updates are notoriously common with an EMR, especially customizations and features needed for meaningful use-significantly more hassle if you need to implement these frequent version changes in-house. 

Given these challenges, starting your EMR journey with a cloud-based solution could save you time and money. It can be especially efficient to do so if you're shopping for both an EMR system and a practice management system; this creates an opportunity for either a single, integrated solution or a pair of solutions that are demonstrated to integrate seamlessly. 

If you've already set up an in-house EMR and it's well integrated with your PMS, moving to the cloud may not have as many obvious benefits. However, once you're facing a large-scale hardware or software upgrade to accommodate your systems, that might be the right time to evaluate converting. This may also be true if your in-house EMR doesn't offer enough patient communication or customization tools to satisfy meaningful use requirements. 

Storing data remotely allows for access from anywhere using the Internet, so, for example, a cloud-based EMR allows urologists in your practice to access and update charts from home or on the road using a smartphone or tablet.

What is cloud computing, and how can it help your urology practice?

It's also important to understand why employees are repeatedly leaving a key staff role of their own volition. You or your practice manager should be conducting exit interviews to understand why employees keep leaving. If, for example, conflicts are creating an unpleasant work environment, you'll have the opportunity to address this situation before the next employee is hired. Sometimes, training issues emerge through exit interviews. Learning this gives you a chance to take corrective action. 

Often, the reasons for turnover are simple: Your lowest level jobs pay low salaries and don't really offer much variety or responsibility. While some people appreciate predictability in their work, others require a sense of growth and progress over time. In a larger urology practice, you may be able to address these issues by offering your employees a career path and possibility of promotion and new challenges. But there are often limits to what you can offer, and smaller practices may have little flexibility. 

When some of your staff jobs are by-necessity routinized and require a limited range of skills, it can be difficult to find someone who wants to stay in them forever. What's more, you can't afford to sacrifice commitment to quality or attention to detail in exchange for longevity-and when you hire for those skills, somewhat faster turnover is likely, since the most attentive and committed employees will have more options and may be more ambitious. 

In situations like this, your practice might be better off hiring, say, an energetic recent grad who wants to go to nursing school in a year-opting for completely predictable turnover-instead of trying to find the perfect long-term hire who just may not exist. 

 In situations like these, the key is to plan for the revolving door; accept that in order to have committed and energetic staff, you might need to incur the costs of replacing them more frequently. The goal is to minimize the costs and errors and maximize productivity. For example, cross training will help ensure you don't suffer productivity losses-or worse, errors-when an employee departs. (This can also help keep your more ambitious, variety-seeking employees interested in their jobs a bit longer.) Making sure your job descriptions, employee manuals, and other documentation are refreshed at least yearly will help accelerate training for new employees. To speed up replacement times for employees, analyze the effectiveness of the media you use for recruiting so you know what is likely to work best. (Get plugged into social media, too; tools like LinkedIn and BranchOut can be very handy for quickly getting the word out.) 

Keeping open communication with all your employees can also help you manage turnover and transitions better. When you know an employee is planning a big step like going back to school, let him or her know that a long notice period-3 or 4 weeks instead of the traditional 2-would be appreciated, and not punished with a request they leave sooner. And, sometimes your ambitious exiting employees will also appreciate an option to work part-time while you look for a replacement-a win-win that can help everyone involved. 

is a senior health care consultant with Capko & Co. who specializes in research, marketing, social media, business development, and strategic planning. 

is a health care consultant and the author of 

Take Back Time-Bringing Time Management to Medicine

Whenever an employee leaves, you incur expenses to advertise the open position and set up and train a new employee. And, of course, there can be productivity losses in the interim.

Urology staff turnover problems require careful analysis

It may be tempting to reject altogether the notion that process optimization is relevant to your urology practice. After all, urologists help human patients with highly personal health concerns, not mechanical "inputs." The irony of bringing manufacturing thinking to practice processes is that by improving them, you will be able to improve the patient experience-and make it less dehumanizing, not more so. 

The essence of manufacturing efficiency is to continually examine processes and incrementally improve them by eliminating wasted efforts and errors. Wasteful, inefficient processes are irritating to patients, and they cost your practice money. Root them out and your practice will be more profitable, and your patients will be happier. 

 Sometimes confused with expense cutting or maintaining a small staff, the "lean" discipline is really about the identification and elimination of wasted resources and, especially, wasted time. In a medical practice, hidden time wasters affect both the patient experience and the bottom line. 

Preventable process problems are another hidden source of waste. Preventing problems usually takes a lot less time than resolving them. For example, failure to alert patients that they'll be expected to pay their portion of their bill at the time of service is a hidden source of waste. Some practices "save" time by not determining patient responsibility payments prior to patient visits or explaining payment expectations to patients. But patients who are unprepared for what they'll owe are more likely to question or object to bills they receive after the fact. This creates more work for the staff to explain the bill and collect it, and more costs when some of the bills go unpaid. 

Preventable no-shows are a huge source of waste for practices. Optimizing reminder calls, e-mails, and text messages is an investment in protecting the practice's most precious resource: provider time. 

 Modern manufacturing recognizes that waiting is inherently costly. When inventories sit on the factory floor, they represent money tied up in the materials used to make the products and rental costs for the space they occupy. 

In a medical practice, excessive patient wait time is a sign of inefficiency. It's costly because waiting patients need a place to wait, because waiting patients need staff attention, because some will need to reschedule if the wait is very lengthy, and because some patients will simply find another urologist if they're repeatedly annoyed by waiting. 

Other types of waiting create inefficiencies in a practice but are easy to address. Answering phone calls as they come in, rather than letting messages pile up during lunchtime, requires much less staff time, because returning a patient's call may take several attempts. Billing daily, rather than accumulating large batches of waiting bills, also saves money by bringing revenue into the practice more promptly and enabling any coding or documentation problems to be solved more easily, when they're still fresh in providers' minds. 

 The Japanese philosophy of continuous improvement, or "kaizen," was pioneered by Toyota after World War II. The idea is that constant incremental attention by everyone in the organization can help find and resolve problems and waste, and eliminate errors over time. 

Empowering staff is central to the concept of continuous improvement. Toyota was the first to recognize that management's view of work processes could be a lot less clear than the line employees' perspective. This is a powerful concept for medical practices, since practice operations are often invisible to physician managers. Allowing (and encouraging!) employees to identify problems and suggest solutions not only provides physicians and practice managers with more accurate information about workflow problems, but it also motivates staff members by recognizing the importance of their contributions. Many aspects of a urology practice's workflow will change over time, with the introduction of new treatment options, tests, and billing rules. Your team is the best resource you have to ensure your processes remain efficient as needs change. 

 is a senior health care consultant with Capko & Co. who specializes in research, marketing, social media, business development, and strategic planning. 

 is a health care consultant and the author of 

More on improving your practice's processes							

With all of the complexity involved in the nonclinical side of practicing medicine, hope exists. And the word of the day is efficiency, says Frank Cohen, MPA, in an article in 

Cohen explains the tenets of process improvement, including two major process improvement models: Six Sigma and "lean." 

Six Sigma, as the name implies, was founded on the idea that, in any process, one can experience a variation of six standard deviations from the mean (hence the term sigma) and still be in control or still meet specifications. 

The second model, referred to as lean, focuses on reduction of waste-wasted movement, wasted resources, wasted energy, wasted space, etc. As a pure model, it not only is more applicable to health care but now is becoming widely accepted as a business management model. 

									http://www.urologytimes.com/processimprovement/

Using manufacturing principles might seem like an odd fit for your practice, but they can help your practice move more efficiently.

Judy Capko

Articles

Your high-maintenance urology office staffer: Worth the hassle?

What is cloud computing, and how can it help your urology practice?

Urology staff turnover problems require careful analysis

How to turn your urology practice into a well-oiled machine