For the first few years of my career I was my own secretary. The hospitalist group I was part of ranged in size from two to nine doctors, and each of us handled all our own telephone correspondence and paperwork without clerical help. If you looked up our “office” phone number in the hospital’s physician directory you would find each individual’s pager number.
As a result, each of us got many pages every day regarding routine administrative issues such as hospital medical records, death certificates, and billing questions. Sometimes I felt as though I were answering nearly as many calls via pager as the hospital operator. And the pages about important clinical issues were mixed with all these routine inquiries.
While doing without clerical support in a hospitalist practice can help keep your overhead really low (ours was always well under 10%), it is not an efficient way to operate. A nonclinical support person is nearly always worthwhile. But, while the group I was part of made the mistake of trying to do without such a person (a problem we eventually fixed), a number of groups make the opposite mistake and hire too much clerical help, making it difficult or impossible to justify the cost.
Think carefully about clerical support positions. Unfortunately, in many practices in which the hospitalists are employees of the hospital, the doctors may not be engaged in deciding the optimal role and staffing (number of fulltime employees, or FTEs) for this position. To the doctors, it feels as though this person doesn’t cost them anything (in many cases the doctors aren’t paying for it directly, the hospital is), so they might not spend a lot of time thinking about whether they’re really getting good value for the money. But the doctors are in a much better position than other hospital administrators to know whether that position optimally supports the practice.
The amount of staffing and precise job descriptions will vary tremendously from one practice to another. I want to offer some general guidelines worth consideration by nearly all practices. This discussion is not about support personnel, such as case managers dedicated to the hospitalist practice, midlevel providers, or other clinical support staff. This discussion is really about the front-office support staff for your practice.
How Many to Hire?
My experience suggests a hospitalist practice should have about one FTE of clerical support for every five to 15 FTE hospitalists. The optimal staffing for a particular practice will vary depending on the person’s precise responsibilities. A practice that operates at more than one site (e.g., one hospitalist group covers two hospitals) will usually need more support than one that operates in one hospital.
Practices smaller than five or six FTE hospitalists often need less than full-time support. They might work well using part-time clerical support from an existing member of the hospital’s staff, such as someone in administration or the medical staff office. In many cases this might mean the person has one incoming phone line dedicated to hospitalist calls and another dedicated to the other activity. Depending on which line rings, he/she answers by saying, “hospitalist office,” or “medical staff office.” Usually it is best for the person to be responsible for both activities all day long and not divide his/her time into working for the hospitalists only until noon, then spending the rest of each day supporting the other activity. Until the group I am currently part of grew to eight FTE hospitalists, our clerical support person had a full-time job—half of which was devoted to supporting our practice and the other half to supporting the hospital’s Institutional Review Board (IRB).
Define the Job
There are a number of common ways for a support person to contribute to the practice, which I have grouped into several broad categories:
Handle telephone correspondence. This person should answer all calls to the practice’s main office number. Most practices will have a separate number for billing inquiries, and clinical calls from the hospital’s nursing staff are usually paged directly to the doctor by a nurse. But that still leaves a lot of calls that will go to the support person, such as administrative questions about the practice, calls from former patients (who have been discharged) and families, pharmacies (e.g., asking about refills), funeral homes, and others.
Some practices use a “triage pager” system in which all calls about new referrals to the practice (e.g., from ED doctors, referring PCPs, surgeons requesting consults) always go to the triage pager—day or night. Usually the individual doctors take turns carrying and responding to the triage pager, and after hearing about a referral to the practice they will call the doctor who is up next for new patients and pass the information along. In a large practice, that pager can generate a huge number of daytime calls, making it difficult or impossible for the person holding the triage pager to also care for patients.
Some practices have found that the practice clerical support person can take all those calls during the daytime Monday through Friday and pass them along to the appropriate hospitalist. The clerical person would typically get only the patient name and location and the referring doctor’s name and contact information, then page it to the hospitalist next in line for a new referral. That hospitalist would then call back the referring physician to get more clinical information. That relieves a member of the practice from taking all the calls. And, it puts the referring physician directly in contact with the hospitalist who will see the patient, rather than a triage doctor who won’t be caring for the patient. This should mean a better handoff.
Handle paper correspondence. This person can sort all the faxes, mail, and medical records that come to the practice, and put them in each doctor’s mail box in the office. He/she might initiate work on some forms. For example, upon arrival of a form to certify medical necessity for a piece of equipment (e.g., home oxygen ordered on a patient recently discharged) he might open the envelope, complete as much of the form as possible, attach the relevant records from the hospital stay, and leave all this for the doctor to sign.
Another potentially critical function is to request and pursue outside clinical records requested by one of the hospitalists. For example, a hospitalist admits Ms. Smith at 1 a.m. and realizes it will be helpful to get previous creatinine values from the PCP’s office and the report of a prior cardiac cath from an outside hospital. The hospitalist could simply record a voice mail (at 1 a.m., while seeing the patient) requesting that the practice assistant track down these things the next morning. That might include ensuring an appropriate release-of-information form is signed by the patient and faxed to the outside facility. When the records arrive, the assistant would place them on the patient’s chart (and, if necessary, page the hospitalist to report that the records have arrived).
Support billing functions. Practices use many strategies to ensure good documentation, coding, charge capture, and billing. The assistant might play an important role in this process. For example, the doctors might first report all charge data to the practice assistant who reviews it to make sure there are no conflicting charges (e.g., two doctors bill the same service to a patient on the same day) and no missing charges (e.g., a doctor forgot to submit a charge for one day of a patient’s stay). The assistant can be the principle connection between the doctors and the billing service and might be the first person to troubleshoot problems encountered by the billing service (e.g., getting additional documentation, figuring out which doctor can best address an ICD-9 code that lacks a fifth digit).
Perform general practice administrative functions. The assistant can keep track of when each doctor needs to renew his or her state license, DEA certificate, ACLS certificate, as well as keep track of total hours of CME (e.g., know how many more CME hours each doctor needs this year for state licensing requirements). He/she could also assist in various human resource functions such as ensuring each doctor responds during the open-enrollment period for benefits each year.
In some practices it is appropriate for the assistant to create the physician work schedule for the next month, quarter, or year, and serve as the main point of contact for any schedule change the doctor’s need to make. However, for groups that use a complicated scheduling system, the doctors will often need to take an active role in its creation. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.