Originally published in Pain Medicine News; reprinted with permission

Dear Arizona Pain Specialists:

I have a bustling medical practice that I can barely keep up with; I need to hire more mid-level providers, possibly find another physician and do some research on opening another location. Additionally, I need to obtain Meaningful Use qualification and ensure my growing staff is HIPPA compliant. The problem is, I can’t do all of these things and practice great medicine. I have a family with young children whom I’d like to spend more time with, and I haven’t seen a golf course in two years. There simply isn’t enough time in the day. I’ve considered hiring an office manager to help sort through some of these herculean tasks, but I am not sure what to look for. Help!

Sincerely,

- Rather Be Golfing

Dear RBG,

You are to be applauded! You’ve crossed the first, and possibly largest, barrier to having a wildly successful practice: You’ve realized it takes a team. You, as the quarterback, are in charge of leading your health care practitioners and medical staff to provide the very best care to your patients. Now, it’s time to build a team around you. This team should be composed of individuals with experience in business, human resources, compliance, marketing, information technologies, billing and office management.

Let’s assume you have a stack of resumes from your city’s best applicants for the office manager position. Your advertisement for the job suggested a lengthy list of large- and small-scale projects you want accomplished for your practice. Those who have responded vary in experience and education. How do you decide who is the best fit? Consider the following items during your interview with each candidate to help you make your final decision.

Presence

The old adage “first impressions are lasting impressions” holds true. Although it is illegal to judge your candidates for their age, sex, race or sexual preference, it is quite appropriate to judge them by the way they present themselves. Keep in mind that this person will be responsible for representing your name and your practice in the community. He or she may be responsible for negotiating contracts, hiring other staff members and speaking with the media on your behalf. During the interview, consider the following:

• Did the candidate show up on time?
• How is the candidate dressed?
• Was the candidate prepared for the interview (did he or she do initial research about your practice and your mission)?
• Is the candidate’s resume in top form?

It is not superficial to reduce your candidate pool because of misspellings on a resume or tardiness to an interview. With today’s economy, employers have the privilege of being extremely selective. There are more applicants than ever before who are likely overqualified in both education and experience, but due to the recent economy are unemployed and eager to return to the workforce. Therefore, the minor details of first impressions are significant. With so many great applicants available, you are wise to be highly selective.

Substance

This criterion is most important after you have narrowed your selection of candidates to no more than three. Most likely, all of these candidates are well educated, have strong references and have valuable experience. However, are they able to solve problems? Are they critical thinkers? Are they detail-oriented? Can they take a large project—like opening a second office—and organize it into comprehensive steps?

The right candidate will be able to “eat the elephant one bite at a time.” An office manager will essentially serve as a project manager, responsible for the execution of numerous projects across many different areas of a practice. This will require and someone who is extremely organized and detail-oriented. Successful project completion first requires successful navigation of each of the traditional stages of project management. These include:

• project strategy;
• preparation;
• design;
• development and testing;
• training and business readiness;
• support and benefits realization; and evaluation.

Within each of these stages, an effective manager will provide the following:

• phase management;
• control;
• team management;
• communication;
• procurement; and
• integration.

It is possible these seem like a series of buzzwords that do not truly equate to your end goal: crossing things off your business development to-do list. However, an effective office manager should be able to think within these stages and recognize that their completion is a recipe for success.

To determine how your candidates respond to a large-scale project, conduct a test during the second interview. Provide the candidates with a sheet of paper and pen, and give them 15 minutes to detail, in stages, how they would launch a second location for your practice. To prevent outside research, ask the candidates to turn their phones off prior to the test. Encourage them to take as many notes as they wish on the single sheet of paper.

The right office manager for your practice may not have extensive experience in either health care administration or practice development. However, the best candidate will be able to show, in steps, how he or she would start the process, and the research involved in doing so. When examining the candidate’s notes, consider the following: Do you follow his or her brainstorming? Is his or her line of thinking logical and rational? Are detailed solutions and steps included in the plan? Are there creative ideas you might not have considered?

The right candidate’s intelligence and problem-solving skills should shine, regardless of the fabricated project you present for testing.

Personality

Let’s assume you have identified three candidates with strong problem solving and critical thinking skills —two key characteristics of a strong office manager. These candidates also present themselves well and communicate effectively.

Now, it’s time to let your staff do the interviewing. Select several key employees with whom the candidate will work regularly. Perhaps this is a nurse practitioner, lead medical assistant and billing coordinator. For a second interview, have your candidate spend 15 to 20 minutes with each employee, while demonstrating a complicated task the employee is responsible for performing. Provide the employee with a list of questions to keep in mind to answer after the working interview. These should include:

• Is the candidate friendly?
• Does the candidate ask questions in a clear manner?
• Did the candidate truly listen?
• Did the candidate understand the process?
• Did the candidate take notes?
• What is your gut feeling?

It is likely, and to be expected, that your candidates will not understand complicated processes after spending only 20 minutes with an employee. However, the right candidate will take notes, be respectful and ask appropriate and logical questions. Most importantly, the best candidate will work well with all three employees you selected, and will demonstrate curiosity, intelligence and the interest to better understand your practice.

Experience

Once you’ve heard from your staff about the working interviews, it is time to take the final, and perhaps most practical, aspect into consideration: experience. Which of the candidates has management experience? Does the candidate have strong references supporting successful project management? Keep in mind, these “projects” may not be health-related. It takes the same skill set to be an event planner as it does to be a successful office manager, including organization, effective communication, diligence, honesty, and developing and adhering to a budget.

It is important to rely on staff feedback and the other areas you examined during the interviews. It also is important to rely on your intuition. The right candidate will fill you with confidence that the future of your practice is in the right hands. It might be helpful to provide a list of clear objectives and expectations to the person you hire, and offer a 90-day trial contract. After three months it should be clear whether you have hired someone with the presence, substance, personality and experience to be a successful office manager. By hiring an applicant that excels in all four of these areas you will have found a manager that is not only a great fit for your practice, but also someone who is able to help your business reach new levels of success.

Drs. McJunkin and Lynch founded Arizona Pain Specialists, a comprehensive pain management practice with three locations. They teach nationally and are consultants for St. Jude Medical and Stryker Interventional Spine. Through their partner company, Boost Medical, they provide practice management and consulting services. Ms. Donley is a project manager with Boost Medical and is responsible for the oversight of several pain management practices. For more information, visit ArizonaPain.com and BoostMedical.com.

Originally published in Pain Medicine News; reprinted with permission

By Paul Lynch, MD, Tory McJunkin, MD, Ryan Tapscott, PhD, Trudy Madan, MHA, and Sheri Campbell 

Dear Arizona Pain Specialists,
I recognize the technologies of pain management are always changing. I want my practice to be innovative—not just reading about the latest breakthroughs, but actively involved in finding them. Should I consider bringing clinical research trials in-house? How do I involve my practice in research and what do I need to do to be successful?

Sincerely,
Unsure About Research

Dear Unsure About Research,

In addition to completing the necessary training to become a clinical research investigator, physicians also must consider how to build the proper infrastructure in order to be successful. Clinical research tends to be most successful when it is integrated into the overall workflow of the practice, which requires the collaborative efforts of many different departments, including marketing, billing, patient concierge, facilities and information technology, as well as operations and clinic processes. The specific responsibilities of each department are as follows:

• Marketing departments develop advertisements and recruitment materials, help with recruitment strategies, obtain referrals, post information about your research, direct people to the Web site and make flyers and brochures to give patients.¹
• Billing departments assist in identifying all clinical trial costs, determine and designate standard-of-care costs versus sponsor-paid costs, identify and document research participant and services, link research charges to research study account and budget development.¹ It often is necessary to create separate billing and scheduling for study patients to ensure you are extremely careful not to double dip (e.g., being paid for research visits by a clinical trial sponsor and also charging patients for the same visit).
• Patient concierge departments schedule patients for study screenings and follow-up visits, answer patient questions and concerns, and work to obtain patient records.
• Facilities and information technology departments ensure your site has the necessary research equipment, storage, archive space and secure data management servers.
• Operations and clinic processes departments integrate clinical trial protocol into existing workflow across all facets of patient visits in clinic.

Once you have established the infrastructure needed to accommodate your first clinical trial, it becomes much easier to conduct future trials. The first trial for which you are a principal investigator likely will come with a steep learning curve, but that will pay off with future studies.

If a sponsor believes you have the infrastructure and patient population to meet study criteria, they will schedule a prestudy site-qualification visit. During this visit, a representative from the sponsor and possibly the clinical research organizations (CROs) they are working with will visit your practice to determine if your site is qualified to participate in the trial. The sponsor will likely review the original site information survey that assesses your patient population, equipment for research purposes, the infrastructure you have in place, personnel who will work on the trial and overall space needed to comply with the study protocol.

At this point, you will probably not have access to the study protocol, but you can still establish a majority of the research infrastructure. If you are selected as a site, you will receive the study protocol. At that time, you will want to make it a priority to modify your current workflow and operations to meet the study obligations defined in the protocol. One way to make a great first impression on the sponsor is to show that your practice is prepared to conduct research by having study equipment already purchased and set up. Some common research needs that apply to almost all clinical trials include personnel, workspace and an institutional review board (IRB).^2,3

Personnel include a medical doctor who serves as principal investigator, a dedicated study coordinator and any additional staff who will be subinvestigators. Workspace is needed for the study coordinator and study monitor when they visit to review completed case report forms. An IRB is required to protect the rights, safety and well-being of participants in a clinical trial; either a local IRB (at the study site or within a couple of miles) or a central IRB (a commercial IRB that provides services for multiple sites) may be used. A workspace requires a range of things, including a telephone, Internet access and email capability, a fax machine, a refrigerator and freezer, storage facilities (usually shelving, drawers and locked cabinets) for housing case report forms (CRFs), a study drug or investigational agent, and other materials for a specific study (eg, liquid nitrogen dewar, centrifuge, urine drug screen cups). You also may need to hire a pharmacist, a phlebotomist and technical support, depending on the specifics of the protocol.

Shortly after the site-qualification visit, you will be notified whether or not your practice was selected as a research site. If selected, you will need to complete the remaining regulatory documents, including FDA form 1572, which declares the investigator will abide by federal regulations regarding the use of drugs in an investigational setting, medical licenses and good clinical practice training certificates, to name a few.

You will also receive a clinical trial agreement (CTA), a study protocol and a budget for review and approval. The protocol specifies your duties and obligations during the trial. Medscape.com provides a set of nine questions to consider when evaluating a protocol and determining if the trial is right for your practice (Table).

If you approve the CTA, budget and protocol, and agree to become a study site, you will have to obtain IRB approval and prepare for a site initiation visit. Usually the CRO will take the practice information you have provided and submit the IRB application on your behalf. There are other instances in which you will have to prepare an IRB application and submit it to a local or central IRB for approval. Fortunately, the study sponsor will have already created the study documents, so you only will have to complete the IRB application for your site.

The Final Steps To Getting Started

The last step before actual recruitment and enrollment of participants is the site initiation visit. Usually a clinical research assistant (CRA) from the sponsor’s CRO will conduct this visit. During the site initiation visit, a CRA will provide a detailed tour of the study protocol and discuss all necessary study procedures, including the screening process, enrollment, randomization and treatment assignment, data capture using CRFs (or electronic CRFs), follow-up visits, adverse events and study termination. The site initiation visit can last several hours and normally the study coordinator is required to be present for the entire meeting. The principal investigator also will be required to attend a portion of the meeting. The overall purpose of the site initiation visit is to provide complete study training to ensure that you and your site are completely prepared to complete all study procedures.

Following the site initiation visit, your practice’s focus should be on recruiting and enrolling as many patients as possible who meet study criteria. Nearly 80% of trials fail because of an inadequate number of patients, so when you are trying to land clinical trials for your site, your primary selling point should be your ability to populate the study, making sure you can back up your promises.⁴ Meeting your target enrollment goal is the best way to ensure your site is selected for future clinical trials.

Establishing all the components of a clinical research program can be daunting, as it takes significant time and start-up costs. Consider it like any other investment: Be smart about selecting trials, be diligent in your review of the protocol and CTA, adequately prepare your practice and staff and closely monitor the day-to-day operations of the research so you can prosper in the long run. A successful clinical research program can result in numerous achievements for you and your practice⁵:

• Developing staff professionally
• Being at the forefront of new pain management treatments
• Developing research partnerships and collaboration with other physicians
• Working with investigational medications and products
• Gaining professional recognition (often contingent on number of patients enrolled in study)
• Presenting research at national conferences, speaking at conferences and other educational events and co-authoring papers
• Earning continuing education credits
• Helping in the design of future protocols
• Being viewed as a leader within the field by assisting in the development of breakthrough drugs and treatments
• Gaining personal satisfaction
• Offering patients treatments that may not be available elsewhere
• Playing a pivotal role in the advancement of pain management by helping establish new medicines and medical devices
• Gaining a new revenue stream
• Receiving compensation from sponsors for successfully conducting clinical trials through enrollment of participants and completion of follow-up visits
• Properly executing studies can net practices as much as $58,000 in revenue, with net income as much as 40%.4

Although beginning a clinical research program will take a lot of time and effort, if executed properly it can be an extremely rewarding endeavor. Clinical trials are at the heart of all medical advances. Carefully conducted, quality clinical trials are the world standard for identifying and developing the best possible methods to prevent, detect and treat medical conditions and diseases, as well as develop new medical devices and procedures. These trials have the potential to change the course of pain management and the lives of patients suffering from chronic pain. In becoming an active clinical researcher, you put yourself and your practice at the forefront of a rapidly advancing field that you can help shape.

References

1. Arimendy C. How to start doing office-based clinical trials. June 9, 2010. www.medscape.com/viewarticle720916. Accessed January 26, 2012.
2. Stone J. Conducting Clinical Research: A Practical Guide for Physicians, Nurses, Study Coordinators, and Investigators. 2nd ed. Cumberland, MD: Mountainside MD Press; 2010.
3. Ginsberg D. Becoming a Successful Clinical Research Investigator. 2nd ed. Boston, MA: CenterWatch; 2009.
4. Rollins G. Physicians find clinical research brings income and treatment options. August 1, 2002. www.sendemissary.com/Focus-on-Clinical-Investigators-Coordinators/clinical-research-benefits-for-physicians.html. Accessed January 24, 2012.
5. Clinicaltrials.com Knowledge Center. www.clinicaltrials.com/knowledge_center/?faq_category=Investigators#. Accessed January 24, 2012.

Drs. McJunkin and Lynch founded Arizona Pain Specialists, a comprehensive pain management practice with three locations. They teach nationally and are consultants for St. Jude Medical and Stryker Interventional Spine. Through their partner company, Boost Medical, they provide practice management and consulting services to other pain doctors throughout the country. For more information, visit ArizonaPain.com and BoostMedical.com. Ms. Madan, MHA, is the CEO and Ms. Campbell is the vice president of marketing and operations for Synergyst Research. For more information, email trudyi@synergyst.net or call 210-447-2080.

Originally published in Pain Medicine News; reprinted with permission

By Paul Lynch, MD, Tory McJunkin, MD, Ryan Tapscott, PhD, Trudy Madan, MHA, and Sheri Campbell

I recognize the technologies of pain management are always changing. I want my practice to be innovative—not just reading about the latest breakthroughs, but actively involved in finding them. Should I consider bringing clinical research trials in-house? How do I involve my practice in research and what do I need to do to be successful?

Sincerely,

- Unsure About Research

Dear Unsure,

Although there may always be national debate about whether health care should exist as a universal or private entity, we agree health care is a necessity. Humanity depends on, wants and needs good health care without hesitation. As the health care industry develops and expands in various sectors, such as nursing, health care services and products, job opportunities broaden in response. Such innovation is why health care is one of only a couple of industries that has continued to grow during the economic downturn in the United States.

Clinical research is regarded as one of the fastest growing sectors of biotechnology and pharmaceuticals; it is an imperative segment that supports growth in several divisions of the industry. Clinical research is considered a necessary component for these particular health care sectors to thrive because it provides insight into new medications and treatments for various illnesses. Without research, the field would remain stagnant. The clinical research industry requires many spheres of professional collaboration. Such demand for new technologies, paired with professional collaboration, has created continuous growth in this industry, resulting in the creation of a growing number of career opportunities.

Clinical research requires collaboration between fields. To successfully conduct a clinical research trial, experts from many areas must work together. Such groups include, but are not limited to, clinical research organizations, pharmaceutical sponsors and physicians. Essential positions fulfilling these specific needs include clinical research coordinators (CRCs) and clinical research assistants who work on research study teams with physicians. Clinical research requires a successful integration of medicine and business by providing opportunities for employers, physicians and patients, as well as pharmaceutical and corporate research companies.

Clinical trials may be categorized as one of the following:

• Treatment studies test new treatments, new combinations of drugs or new approaches to surgery and/or therapies, such as radiation or physical therapy.
• Prevention studies investigate better approaches to eliminate disease, which may include medicines, vaccines or lifestyle changes.
• Diagnostic studies evaluate better methods of testing, or procedures for identifying a particular disease or condition.
• Screening studies investigate and determine the best way to detect certain diseases or health conditions.
• Quality-of-life studies (or supportive care studies) explore and measure ways to improve the comfort and quality of life of people with a chronic illness.

During the past 20 years, the science of performing clinical research has evolved. The pharmaceutical industry has seen mergers, acquisitions and layoffs, but clinical research is still thriving. Clinical research organizations (CROs) have seen consistent growth in revenue. Even when unemployment rises, CROs see the benefit of increased patient involvement.

The following examples showcase patients’ reasons for participating in recent research:

• Participants gain access to new medicine, therapies and/or medical devices before they are available to the public.
• Participants in clinical research are given an additional treatment option that may not otherwise exist.
• Investigational products may prove to be a more effective treatment than the current standard of care.
• Participants receive frequent and in-depth individual medical attention from a research team of doctors, nurses, scientists and other health professionals.
• Participants feel heroic for contributing to the advancement of medicine.

When a patient chooses to participate in clinical research, he or she may receive the following services at no cost: medications, devices, supplies, medical exams, and laboratory and diagnostic tests. Patients also may receive compensation for their time and travel.

Carefully conducted clinical research studies are seen as the fastest and safest ways to find effective treatments, improve standard of care and identify methods to improve health care. Participating in clinical research is essential for the development of new medications and new treatments. Not only do participants experience full benefits at no personal expense, they also have the satisfaction of knowing that results from research studies may help others in the future.

Getting Started in Clinical Research: How To Find Trials

Web sites, such as CenterWatch.com or Clinicaltrials.gov, can help those interested in participating find clinical trials. On Clinicaltrials.gov, you can perform keyword searches based on topic and location (e.g., chronic low back pain & Scottsdale, Arizona). If you find a trial that interests you, reach out to the point of contact listed to inquire further. There also are Internet databases where physicians can submit practice information and select diseases and illnesses they would prefer to study based on their patient population. Other possible means of identifying clinical trials include contacting drug or medical device companies.

There also are companies that exist to help match practices with clinical trials. CROs are contracted by study sponsors to find appropriate study sites and conduct the studies for the sponsor; site management organizations (SMOs) help physicians identify and apply for clinical trials.¹ These organizations vary greatly in the services they provide to physicians who are looking to become principal investigators. For example, if a physician wants to conduct research, but has little to no research staff, an SMO can provide complete management of the site’s clinical research, from assisting in institutional review board application completion and other documentation, building a site’s needed infrastructure (including staff support and equipment), as well as assisting in patient recruitment and the logistics necessary to build the study protocol into a practice’s workflow.

On the other hand, if a practice is well equipped with a CRC, research staff and other infrastructure needed to be successful, a SMO can serve as a liaison between the clinical trial sponsor and the site. SMOs such as Synergyst Research are great at locating clinical trials that match a practice’s patient population, and are instrumental in helping a site complete all necessary regulatory documents to apply for a trial, prepare for a prestudy site qualification visit, negotiate the study contract and excel at ensuring a site is recruiting and enrolling patients.

Identifying Research Personnel

Finding interesting and appropriate clinical trials is only the first of many steps to conducting clinical research. There are a number of vital personnel that you will need to ensure the success of clinical research at your practice. These include a principal investigator, CRC and subinvestigators.

The role of principal investigator is normally filled by a medical doctor whose responsibilities include, but are not limited to, making medical decisions, ensuring proper care is given to study patients according to the study protocol, adhering to numerous regulations and other ethical standards for human participant research and protection, and controlling and accounting for study drugs.²

Often, new physician-researchers fail to realize the extensive management and documentation inherent to clinical trials; they begin a clinical trial scrambling to try and accommodate these demands. It is important to have a competent CRC who is designated to handle the day-to-day clinical research tasks. Physicians serving as principal investigators generally are too busy seeing patients and managing their business to also handle the day-to-day clinical research tasks, so a competent, dedicated CRC can take a lot of pressure off the principal investigator over the course of a clinical trial.

At Arizona Pain Specialists, a PhD serves as our research director. He arrived at our practice with the requisite skill set needed for us to be successful in clinical research, which has saved us many headaches in the long run. Not every site will be able to hire a PhD-trained researcher, but there are certain traits one can seek when hiring a CRC. These include someone who is intelligent, self-sufficient, pleasant, flexible, charming, compulsive, detail oriented and well organized. Although medical knowledge would be a plus, it is more easily acquired than the other qualities (especially because other medical personnel already on staff can serve as a source of this knowledge).

A CRC is sometimes referred to as a jack-of-all-trades because research permeates all areas of a practice (i.e., marketing, billing, scheduling, patient relations and interaction, facilities, and operations and processes).¹ In a given day, a CRC may wear all of these hats, in addition to performing general research duties, which include scouring patient charts for study candidates, patient recruitment, patient follow-up, consenting, gathering and recording data, collecting specimen, managing and scheduling patient visits, and monitoring visits and other study meetings.

In addition to the principal investigator and CRC, a site may also have subinvestigators. These generally include other physicians, medical staff, lab personnel and anyone else who will play a role in the completion of a clinical trial.

All study personnel must complete important training before being eligible to conduct clinical research. The FDA requires that all research staff complete good clinical practice (GCP) training. GCP is an ethical and scientific quality standard for designing, conducting, recording and reporting trials that involve human participants. Compliance provides public assurance that the rights, safety and well-being of trial participants are protected.³

Our research staff completed GCP training via an online course provided by the National Institutes of Health. Often, a course such as this will be sufficient proof of GCP training, but there are some sponsors that require completion of a specific GCP training and certification prior to initiating a study site. In the case of the protection of human participants, one can never be too careful and have too much training because protecting human rights is paramount. Additionally, research staff will also need a thorough understanding of the principles of conducting clinical trials, including their ethical and regulatory requirements.

See the May 2012 issue of Pain Medicine News for the second part of “Discovering Medicine for Your Pain Practice through Clinical Research.”

References

1. Stone J. Conducting clinical research: A practical guide for physicians, nurses, study coordinators, and investigators. 2nd ed. Cumberland, MD: Mountainside MD Press; 2010.
2. Arimendy C. How to start doing office-based clinical trials. June 9, 2010. www.medscape.com/viewarticle720916. Accessed January 26, 2012.
3. Guideline for good clinical practice. www.ichgcp.net. Accessed January 27, 2012.

Drs. McJunkin and Lynch founded Arizona Pain Specialists, a comprehensive pain management practice with three locations, seven pain physicians, 10 mid-level providers, three chiropractors, on-site research and behavioral therapy. They teach nationally and are consultants for St. Jude Medical and Stryker Interventional Spine. Through their partner company, Boost Medical, they provide practice management and consulting services to other pain doctors throughout the country. For more information, visit ArizonaPain.com and BoostMedical.com.

Ms. Madan, MHA, is the CEO and Ms. Campbell is the vice president of marketing and operations for Synergyst Research. Synergyst Research contracts with physicians to assist with administrative duties and increase clinical research studies. In 2011, Synergyst Research (www.synergystresearch.net) negotiated more than 150 research studies in all specialties.

Discovery Clinical Trials (www.discoverytrials.com) partners with physicians to create research centers within private practices. As of 2011, Discovery Clinical Trials created 19 research center partnerships with physicians across the United States. For more information, email trudyi@synergyst.net or call (210) 447-2080.

Originally published in Pain Medicine News; reprinted with permission

An employee satisfaction survey can help uncover the brutal facts about your business. Such a survey assists in finding the true motivations and passions of the people who make up an organization. By embarking on this bold journey of discovery, you can start to build a great company.

Dear Arizona Pain Specialists,

I understand that keeping my patients and staff happy is important, but I’m not sure how to gauge this. I am often running from the office to the surgery center and then to meetings, so I rarely have enough time to stop and ask, “How is the patient experience?” or “Does my staff enjoy working here?” How can I be certain?

—Successful MD With a Busy Schedule

Dear SMDWABS,

Now more than ever, patients have an abundance of choices in who provides their care. They can easily find ratings and opinions of you and your practice online. Do not despair though—there are proactive steps you can take to engage your patients and your staff to address negative issues. By doing so, you’ll create an environment of healing for patients, and a sense of purpose for your staff.

The answer to your question lies in the idea of confronting the “brutal facts.” In his book Good to Great: Why Some Companies Make the Leap … and Others Don’t, Jim Collins explores this concept and argues it is a cornerstone of running a successful business. More specifically, it is a concept he refers to as “The Stockdale Paradox.” Collins defines the paradox as such: “You must maintain unwavering faith you can and will prevail in the end, regardless of the difficulties, and at the same time have the discipline to confront the most brutal facts of your current reality, whatever they might be.”

Collins argues that the idea of facing an ugly, unhappy reality plagues organizations and prevents transformation of businesses because leaders are simply too far removed from reality. In medical practices, this can be exacerbated by two facts: 1) owners are kept extremely busy as practicing physicians; and 2) owners are also strongly biased. This can create an environment where staff members do not want to speak up when an opportunity for progress is recognized; worse, it can promote a situation where staff buries important feedback (either from staff or patients, or both).

So how does the busy physician-owner solicit such brutal facts from his or her patients or staff? How does a physician who was never made to take an organizational behavior class in medical school create a culture of openness?

It is important to recognize that as a physician you were trained to save the day. When running a business, physicians must learn to accept that they cannot do it all. They need someone they can trust to make decisions when they are busy doing procedures, providing care to patients in the office or building relationships in the community. They need to identify someone who believes in their work; this trusted individual will help create an environment conducive both to quality patient care and meaningful work for employees.

Gauging Patient Satisfaction

When it comes to patient satisfaction, a practice must be prepared to be both proactive and reactive. Physician rating sites like Vitals.com and RateMDs.com are constant, permanent reminders of how easy it is for a patient to leave a clinic and complain. Such negativity can broadcast that the wait time was excruciatingly long, or that the physician’s bedside manner leaves something to be desired. These rating sites are only growing in popularity. The most the physician can hope to do is participate in the conversation and focus on listening to the message, even if the details aren’t exactly as the physician remembers them. By actively engaging patient feedback online, the physician will not only mitigate the likelihood of lashing out, but it will force him or her to “confront the brutal facts.” Physician responses should not be specific, lest they violate HIPAA regulations. Rather, physicians look at making comments as an opportunity to state their philosophy on patient care, and further, acknowledge that they are listening and taking steps to improve the patient experience. Logistically, we recommend that physicians make it the responsibility of one person in the practice to monitor all online posts about their practice. This should take no more than 15 to 30 minutes per day, including a report back to the organization of what was published about the practice online.

But why should physicians wait for patients to leave their office before telling them how much they are appreciated and ask for their feedback? Proactive steps should be taken to engage patients the moment they walk through the practice doors. We recommend two simple things: 1) a five- to seven-item questionnaire on an index card; and 2) a medical assistant asking one additional question: “Is there anything else we can do to make your visit better?” Our patient feedback survey can be found at http://www.boostmedical.com/boostmedical.com.bak/services/surveys-and-patient-feedback.

The task of collecting this information should be assigned to the office manager and he or she should enter the data into a spreadsheet. This will allow the practitioner to generate satisfaction scores for each item and help identify areas for improvement. Additionally, the same manager should take any specific feedback and share both the positive and negative results with the entire staff during a weekly meeting. Staff members should be publicly recognized when they exhibit behaviors that help deliver a better experience for patients. This kind of behavioral reinforcement will, with time, have a dramatic effect on the way a practice responds to patient feedback, and will let patients know that their practitioner cares about their well-being.

Employee Satisfaction

Feelings of pride and self-worth are critical to our happiness as human beings. Because we spend at least one-third of our lives working, being unsatisfied with our job or career can have a major influence on our overall happiness. In a medical practice, it too often can be the case that we focus on a successful outcome rather than the process. When a physician performs a procedure or diagnoses a patient with a complicated condition, it can be easy to forget that there were a lot of pieces to the puzzle that put that patient in the same time and place as you. When we instituted our “Anonymous Feedback Form,” I received disconcerting feedback that one of our employees did not feel that her work made a difference. Because I believe in the mission statement and vision of our company, I thought, “If this employee knew how vital her role is to the success of our business, she would be proud to work here.”

This began a journey diving to the core of what our employees think, feel and believe about our organization, and their individual contribution to the greater whole. I began to ask myself: “Is everyone on the same page?” “Does every person—from the physician to the person answering the phones—know and understand the vision of the company?” and “Do employees understand their unique role in the whole picture?”

As the CEO, I would have to face the brutal facts in discovering the employees’ honest opinions. I knew that these answers would be essential in moving our organization to further success. I had a theory: If any employee who has contact with a patient is unhappy with his or her job, the patient will feel the effects. And thus, patient satisfaction would decrease. Patient satisfaction is most likely directly related to employee satisfaction, so improving one would likely improve the other.

One of the things that make our organization unique is our physicians’ strong interest in research. We have a PhD on our staff who spends most of his time doing business research and clinical trials for our company. He put together a survey asking pointed questions about employee satisfaction. This included work environment, knowledge of the mission statement, whether or not the employee feels rewarded, and most importantly, whether the employee would recommend our facility to their own mom or dad.

I sent an email to the organization expressing some of my goals, which included making our company a highly desirable place to work, for each person to realize the purpose we serve in the community, and to understand the value we bring to patients. The vision was clear: Completing the survey would help us improve. I emphasized the anonymity of the form (which I hoped would help ensure honest feedback) and provided the link to the survey.

I committed to presenting the results to the company within two weeks. Transparency is a key to maintaining a healthy approachability with the employees.

Our Findings

The results were in, and the feedback was indicative of a young organization experiencing a tremendous amount of growth in a short period of time. Some 54.1% of the employees viewed their employment as a job, whereas 45.9% viewed their employment as a career. What’s more, 70% of employees agreed or strongly agreed that our mission statement is clearly defined. This was good news to me. However, I want 100% of our employees to understand our mission. Also, some 87% of employees agreed or strongly agreed that their work makes a difference on a daily basis.

Further statistical analysis showed employees who see their work as a career versus a job, are more likely to believe the organization is a good company to work for, feel that their work makes a difference and believe in the organization’s mission. Moreover, it revealed that the more the employee believes in the company’s mission statement, the more motivated he or she is to do the job, the more he or she believes hard work is rewarded, and the happier he or she is in the position.

Happy employees beget happy patients. A survey like this can be beneficial on multiple levels if the information is used by improving processes, communication and overall morale. However, it is important to realize that it takes time to make significant changes. Even in a young organization like ours, people are creatures of habit and patience is needed to achieve true transformation.

My task was clear: I needed to make sure every employee understood the mission statement of our company. Together our executive staff and I toured each facility, presenting each employee with a card to carry with our mission and purpose statements. I gave a speech charging them to take pride in their work and reminding them that they are each an important part of the big picture. I was astounded that many of our employees had never heard our inspiring story. Each employee now carries the card behind their badge and understands what it means to work for our company.

It’s key to any organization’s success to have a realistic perspective of employee satisfaction. A leader must look at the product of such a survey with the intent to produce positive change and the perseverance to ensure results. It takes courage to examine the brutal facts of an employee survey, but it is a necessary endeavor if one wishes to maximize the potential success of one’s practice. Creating a happy, positive work environment for employees is an integral part of any successful practice; sometimes, achieving this requires a willingness on the part of its leaders to look in the mirror and confront the brutal facts. It’s always easier to look through a window than it is to look in the mirror, but sometimes it is necessary to look in the mirror and realize that change, although difficult, is necessary to improve the culture and success of your business. The results are well worth it.

—Joe Carlon, MBA, Tory McJunkin, MD, Paul Lynch, MD, and Ryan Tapscott, PhD

Dr. McJunkin and Dr. Lynch founded Arizona Pain Specialists, a comprehensive pain management practice with three locations, seven pain physicians, 10 midlevel providers, three chiropractors, on-site research and behavioral therapy. They teach nationally and are consultants for St. Jude Medical and Stryker Interventional Spine. Through their partner company, Boost Medical, they provide practice management and consulting services to other pain doctors throughout the country. Joe Carlon is CEO of Boost Medical. For more information, visit ArizonaPain.com and BoostMedical.com.

Originally published in Pain Medicine News; reprinted with permission

Originally published on Pain Medicine News

Dear Arizona Pain Specialists,

I am a physician-owner of a pain practice in Mississippi, and have begun to hear complaints from several patients about my practice. These complaints primarily center around the staff on the phones being in a hurry, rude and generally unhelpful. None of these complaints are directed at the medical care that we deliver, but I find myself struggling daily to address these needs. What is the missing piece that is preventing my practice from satisfying my patient’s needs?

Sincerely,

Dr. Tele-path

Dear Dr. Tele-path,

A common misconception in medicine is that a patient’s experience, positive or negative, is defined by his or her experience with a medical provider. In reality, what happens before or after the patient visit is just as important as what occurs in the exam room. A great example of this is how your staff interacts with and treats patients on phone calls.

Providing excellent patient care involves making excellent clinical decisions and supporting patients’ needs in and outside of the office. Understanding C.A.R.E. and how it can be applied to your practice will improve the patients’ perception of your practice and of the medical community.

So what is C.A.R.E.?

C.A.R.E. stands for: Showing Compassion for patients, Acknowledging their individual needs, setting Reasonable expectations and providing Excellent customer service. C.A.R.E. is about understanding your patient, whether this interaction is in the exam room or over the phone. It is important to recognize that your phone staff’s contribution to patient care is no less important than the care they receive from medical staff in the exam room, and may dictate the success or failure of their treatment.

Compassion in Action

Compassion is an important attribute for all practitioners of medicine to have, and it is a virtue found throughout the most successful pain management practices. Compassion in pain management starts with understanding that patients often are experiencing severe and debilitating pain along with psychological comorbidities. As a result, pain patients already may be upset or irritable when they interact with your office staff. It is important that every staff member is sympathetic to patients’ pain and makes an effort to work with them so they can receive excellent patient care.

Let’s take this common example. The patient Mary Smith contacts your practice regarding what she describes as “horrible pain,” and demands to be seen immediately. Ideally, Mary Smith would be accommodated, yet in this example there are no available appointments for at least two days. Without a quick option for solving this problem, the response often is simply to tell the patient, “Sorry, there are no appointments and you will have to be seen later this week.” This reaction may be appropriate, but this answer lacks compassion. So what’s another option that may be a more compassionate response?

“Ms. Smith, I’m so sorry to hear that you are in so much pain. Unfortunately, we don’t have any available appointments until the day after tomorrow, but we are putting you on our call list if we have any last-minute cancellations. Please tell me a little bit more about your pain though, and I will see if there is anything that we can do for you in the meantime.”

Notice that, in this instance, a compassionate response doesn’t necessarily mean that Mary is going to be able to get an appointment any sooner. But this response shows that you care about her pain and are validating her condition. It also lets her know that you are working on her behalf and trying to seek an earlier solution to her problem. Providing this level of service shows that the patient isn’t “just another number” with your practice—even if you aren’t always able to meet each person’s immediate demands.

Acknowledging Individual Needs

Although you can establish guidelines or script how a call should go, one of the keys to excelling in customer service is to acknowledge the unique needs of each patient. Although you can’t “know” every patient, you can become an expert at recognizing different tones of voice and allowing the patient to dictate the flow of conversation.

Most patients can be divided into three categories. The first type, the “easy patient,” is going to rely on you to dictate the flow of the conversation. They typically will not ask a lot of questions and will allow you to walk them through the process. Handling this type of patient should be easy—you simply follow all of the normal steps to schedule an appointment and offer them any necessary information. Review important information with this type of patient even if you believe that they already know it, as they probably will not inquire.

The second type, the “busy patient,” wants his or her needs met quickly and is looking for quick and concise answers to questions. They are identified by an impatient tone in their voice, a tendency to talk over you and talk fast. The best thing that you can do for these patients is to rapidly identify their needs, address them, confirm that you have fully assisted them and allow them to proceed with their day. The last thing that you want to do is to keep them on the phone longer than they want to be.

The final type of patient, the “inquisitive patient,” is looking for either extensive information or somebody to talk to. Although these patients do not come along frequently, it remains important that you address their needs. Some of them are looking for a lot of information and are likely to ask many questions. This can be frustrating, but conveying information is important and they should not be faulted for being detail-oriented. Information relayed to any patient should be accurate, and it is especially important with these patients, as they may be taking notes and would remember your name if you say anything incorrect. Other patients are simply looking for somebody to talk to about unrelated matters. You should listen and participate in this conversation, but only up to a point. It is your responsibility to tactfully guide the conversation to a conclusion to avoid potentially jeopardizing other patients’ care by assisting just one person. For example, patient John Stevens, a 78-year-old widower, regularly contacts your practice to “confirm appointments” and to discuss his care plan, but routinely steers the conversation to stories about his life. It is important that you do not simply disregard Mr. Stevens, but also that you steer the conversation to a conclusion. For example: “That sounds very interesting, Mr. Stevens. You have lived a very interesting life. It’s unfortunate that we don’t have more time to discuss that in depth, but is there anything else that I can help you with?”

You are acknowledging that you are interested in his life, but are also reminding him that you are there to assist him and other patients with very specific purposes.

No person or practice will always successfully address every patient’s specific needs, but taking steps to recognize and accommodate individual needs will result in a higher level of satisfaction and, ultimately, more kept appointments.

Don’t Set the Bar Too High

Many medical practices set expectations that turn out to be unrealistic. For example, you might state that your practice “always schedules patients within one week.” If this is going to be one of your selling points, you must ensure that patients actually receive scheduling within one week. Such a statement becomes a requirement both for patients and referring providers. Failing to meet this standard may lead to dissatisfied patients and fewer referrals.

Therefore, do proper research and avoid setting unrealistic goals. You could have employees gauge and report back on the average time patients must wait for an appointment. You should only make the claim that patients are able to get an appointment within one week after verifying that this is indeed possible.

Even when you set realistic expectations, sometimes they will not be met. When this happens, it is important to identify the reason for the discrepancy. If the cause is something temporary, such as a physician being ill or on vacation, carefully explain this to the patient. If the cause is something more long-term—for instance, patient growth outpacing your ability to accommodate patients—the solution may be to temporarily revise expectations. Either way, communication with patients and referring offices is critical.

Making Excellence the Standard

Meeting patients’ expectations for care is important, but exceeding patient and industry expectations can give your practice an advantage. It helps to recognize existing trends in pain management and go beyond the standard. For example, pain management offices generally take patient calls between 8 a.m. and 5 p.m. daily. Although this standard meets most patients’ needs, keeping phones open from 7 a.m. to 7 p.m. provides a service that may accommodate patients whose work hours prevent them from reaching your practice. Finding such niches will set you apart and drive patient satisfaction and referrals.

Despite efforts to provide excellent customer service, mistakes will occur. Recovering from a mistake provides an opportunity for demonstrating excellent customer service. An example of this might be the following: Patient Emily Stone is ordered to receive an interventional pain procedure to treat her chronic low back pain. Ms. Stone is told this in her office visit and that she will be receiving a call to schedule after her insurance has been consulted and she is authorized to proceed. Three weeks pass, and Ms. Stone contacts the office inquiring about her procedure and complaining that she has not heard from the office. After looking into the patient’s chart, it is determined that the information was not properly communicated after her office visit and nothing has been done. Ms. Stone is likely to be upset and steps must be taken to rectify the situation.

Explain the situation to the patient, but also make sure to follow this information with a solution: “Ms. Stone, in reviewing your chart it appears as though we failed to follow through with communicating your procedure order to your insurance for authorization. Now that this has been recognized, we have alerted our authorizations staff and they are going to begin working on this immediately. We will do our best to make certain that this is expedited as much as it can be and will follow up with you regularly during the process.”

Honesty will go a long way with patients, especially if you follow it with a solution that shows that you are going to work to swiftly resolve errors. The person identifying this error should work quickly to communicate the situation to management so that the patient’s needs are met, and hopefully the error is not repeated. If the situation is quickly resolved and the patient is taken care of, he or she will be more likely to view the mistake as a rare occurrence and see the response to the situation as excellent customer service.

Keys to Implementation and Training

Providing adequate training and support for those members of the staff actively implementing the C.A.R.E model is critical to the success of this program. It is important to select staff with strong communication skills for roles involving direct interaction with patients. People filling these roles should complete role-play sessions in order to gauge their response to common situations prior to receiving additional training. A strong candidate should already possess the ability to come up with creative solutions to situations that may occur.

Team members should become well versed in the company’s expectations for dealing with patients. Throughout the training process, you should be clear that individuals will be held accountable for maintaining these expectations.

For areas that are measurable, begin to track and measure performance. Establish guidelines to reward those who promote excellent customer service by exceeding your expectations and consequences for those not meeting their goals. This will drive them to go above and beyond when dealing with all your patients.

Finally, you must be prepared to follow through with monitoring and enforcing those rules and guidelines. This means monitoring calls and interactions with patients to ensure that the messages relayed by staff are consistent with the standards and values of your practice.

Providing proper resources to your team members and following the basics outlined in the C.A.R.E. model will improve patient care outside the exam room, and should return the patient focus in the exam room to treating pain effectively.

Drs. McJunkin and Lynch founded Arizona Pain Specialists, a comprehensive pain management practice with three locations, seven pain physicians, 10 mid-level providers, three chiropractors, on-site research and behavioral therapy. They teach nationally and are consultants for St. Jude Medical and Stryker Interventional Spine. Through their partner company, Boost Medical, they provide practice management and consulting services to other pain doctors throughout the country. For more information, visit ArizonaPain.com and BoostMedical.com.