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    Jacquelin Houze
    Jacquelin Houze, FACMPE

    Editor’s note: This article was adapted from a paper submitted toward fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives. Learn more about ACMPE certification: mgma.com/acmpe.

    Staffing is a complex process of hiring, training, compensating, positioning and assessing employees to enable operational success. In the urgent care setting, practice managers face challenges recruiting and retaining employees to staff practices due to nonstandard operating hours. Determining appropriate staffing models is important. Practice managers must consider budgets, the number and skill of staff needed, staff productive and non-productive costs, staff/provider satisfaction and state regulations.1

    Urgent care continues to evolve due to many market factors. Patients have higher expectations and more knowledge of their healthcare needs. As high-deductible insurance plans saturate the market, consumers are responsible for more of their healthcare expenses and are becoming more educated on the cost difference in urgent care compared to an emergency department setting.

    With demand and complexity rapidly increasing and the need to lower healthcare costs by reducing ED utilization, many patients are choosing urgent care rather than the ED. The average price of an urgent care visit is between $50 and $150, compared to an ED visit of $300 to $3,000. As medical groups shift to value-based reimbursement, organizations must identify strategies that create greater efficiency and cost-effectiveness.

    Urgent care staffing models

    As patient complexity increases with the push from insurance companies and potential penalties on reimbursements to providers, urgent care volumes will continue to grow. Practice managers will have to be able to identify when to change staffing models. Patient needs and market trends will also need to be addressed.

    Patient complexity

    There has been a push across the country to keep non-emergent patients out of the ED and move them into urgent care to lower overall healthcare costs. For some patients, this has led to confusion about where to seek treatment, in addition to leading some into urgent care with potentially life-threatening illnesses. What can appear to be a simple cough or respiratory issue from a virus can be something much more severe. Urgent care has limited ability to run diagnostic tests that may rule out severe medical conditions. Continued patient education and cost transparency may help reduce confusion. Urgent care must be prepared to handle emergencies as they arise.

    Patient volume considerations

    There has been an increase in utilization of urgent care in recent years, and volume is anticipated to continue to grow. In the 2017 Urgent Care Association benchmark study, “Only 11% of respondents anticipated no growth or staying the same in the next twelve months. Despite new competition from other urgent care centers or on-demand services, survey respondents remain optimistic about organic or inorganic center growth.”2

    As patient education and cost transparency measures increase, so does the utilization of urgent care. The healthcare consumer is wiser and more in tune with the medical costs and benefits of urgent care.

    State and local regulations

    Individual states have regulations that differentiate staffing requirements between urgent care and limited-service clinics. A multispecialty group based in Northern Kentucky, near Cincinnati, has five urgent care locations and is required to abide by Kentucky state regulations. “The clinic shall have at least one (1) licensed physician, and at least one (1) registered nurse present during operating hours.”3 The statute restricts staffing and promotes a more creative staffing model to comply with regulations. The regulation also separates small clinics from more complex urgent care centers.

    Current staffing

    When considering onsite staff, the staffing models outlined in Figure 1 were the most popular, influenced by state licensure regulations and anticipated patient volume.4

    Benefits of proper staffing models

    The staffing model chosen for the urgent care clinic directly correlates to the clinic’s success and the contentment of providers and staff. Allowing providers to give input on staffing needs is important in relation to patient care.

    Improved associate morale and turnover

    When assessing staffing models, it is important to consider staff morale and turnover, since the latter is a big issue in the urgent care setting. As staffing is increased and adapted to the environment, turnover may decrease. Factors that affect morale and turnover include appropriate pay and staff working to the highest level allowed by their position or license. Typically, a registered nurse (RN) would not utilize all his or her skills if there are also nurse practitioners (NPs) or physician assistants (PAs) in an urgent care setting. The data in Tables 1 and 2 show the year before additional staffing was added and the year it was added. Two medical assistants (MAs) replaced one RN in this setting. The data shows before and after turnover rates after increasing staff and training the MAs to practice at a higher level.

    It is essential for staff to know their worth through acknowledgment and appreciation. Developing non-licensed associates will give those individuals a feeling of greater importance. “A positive work culture encourages happier employees, promotes collaboration, and inspires creativity.”5 One way to help accomplish this is through continuing education and provider-led training. Promoting a learning environment can build employee confidence and foster a positive culture.

    The tables demonstrate a reduction of associate turnover of more than 20% from 2016 to 2017. The reduction in associate turnover occurred after an evaluation of urgent care needs.

    Patient satisfaction

    Improving workflow and having a higher number of associates can enhance patient perception of care; it allows for more personal treatment; and “has an impact on clinical outcomes, market share, medical malpractice claims and practice, provider and employee efficiency.”6

    Personalizing the patient experience will also lead to improved patient satisfaction. Additional associates provide the ability to offer small touches, such as patient follow-up calls, which can go a long way in improving patient perceptions.

    In addition, having patient wait time posted on the practice website and in the waiting room, as well as offering call ahead appointments or self-scheduling are ways to satisfy patients.

    Increased staffing size

    With a larger staff, practices can be more flexible with schedules and provide less individual coverage during nontraditional hours. “Staffing appropriately provides a competitive advantage over those in their market, improves patient and staff outcomes.”7 Additional staff may also reduce the risk of medical errors and can improve patient outcomes. Having the ability to use an MA to assist injured patients with wheelchairs and walkers can also reduce the fall risk of a patient.

    Provider buy-in

    The scope of practice for MAs includes direct patient care, including obtaining essential health histories, administering medications and assisting with minor surgery. However, they are not trained for patient assessments.

    It is crucial to provide additional training to all clinical staff members to support them in their jobs. Additional training such as casting and splinting, suture removal and ear irrigation will free up providers and help maintain steady patient flow.

    Establish protocols

    Establishing procedures is important when working with MAs. “Clear directions, well-defined protocols, and orders outlined in advance give the MA a structure of how to approach and prioritize clinical and administrative tasks. Of course, the delegating physician will still need to engage the MA actively, but with protocols, directions, and orders in place, there will be far less supervising/micromanaging required.”8

    Advanced cardiac life support regulations

    Advanced cardiac life support (ACLS) is another factor to consider. ACLS makes use of advanced procedures in caring for patients suffering from life-threatening conditions while also incorporating basic life support or BLS procedures. If a clinic has complex patients, practice managers will need to account for the possibility of a code blue occurring, including a policy in place for such a patient emergency. Clinics equipped with ACLS training and equipment will need to staff two medical professionals who can run code if required. Medical offices could include a physician and a nonphysician provider such as an advanced practice registered nurse or a physician assistant.

    Financial impact

    Financial impact also must be considered with urgent care staff. Economic impact needs to be weighed against the benefit of adding staff. While overall staff costs may increase, so can the volume of patients who can be seen. The practice manager will have to weigh the complexity of the patient with the financial implications of increasing staffing volumes to determine what is best for the practice.

    Shortages in qualified healthcare professionals are presenting a growing problem in the urgent care setting. Having the ability to compensate skilled non-licensed associates is a must to retain them.

    Un-licensed staff

    When changing urgent care staffing to MAs, skill level needs to be assessed. Though both nurses and MAs can room patients, MAs work directly under the supervision of a licensed medical doctor. However, they do not have the same level of education as a licensed practical nurse (LPN) or a registered nurse (RN) or require continued education to maintain a license. It is generally up to the practice manager to make sure MAs support their skill set and continued knowledge base.

    Summary

    With the increase in patient volume and the higher complexity of patients visiting urgent care locations, staffing models will continue to evolve. The need for revising urgent care staffing is evident. The dissatisfaction of patient wait times, and staff and provider burnout are causing record staff turnover. The ability to obtain additional staff while attempting to keep overhead to a minimum is challenging.

    Practice cultures can have different effects on employee performance, motivation and engagement levels. Therefore, it’s up to practice managers to create a culture that will help retain employees. Employee morale can be an issue with the amount of hours worked in urgent care. 

    Every employee will bring his or her beliefs and values to the workplace. It’s up to leadership to ensure employees feel part of the team.

    After attempting several different types of staffing models, the practice found success in the following model.

    Staffing always includes two of the following:

    • Physician
    • Advanced practice registered nurse
    • PA 

    By maintaining two licensed providers in the office, the practice will be prepared for the need to perform ACLS at any time.

    With five offices in the urgent care group, the practice rotated two RNs as coordinators. This model also allowed a higher level of training to comply with OSHA and quality inspections. The practice manager relies heavily on the coordinators to help address any onsite issues. In addition, RNs are utilized for training MAs.

    In this type of model, utilizing a radiology technician to full scope is also essential. Radiology technicians were trained in both the front office and back office, making them one of the most diverse associates on the team.

    A positive work culture encourages happier employees, promotes collaboration and inspires creativity.9 Staffing appropriately provides a competitive advantage over practices in their market and improves patient and staff outcomes.10 Healthcare policies must support a patient-centered environment designed to strengthen relationships between providers and patients, utilizing available resources to accomplish these objectives and improve patient outcomes. An unaligned structure creates ambiguity, confusion and lack of accountability.11 Communication and collaboration need to be considered in the overall strategy. These factors include the level of employee training, organizational culture, effectiveness of communication channels and monitoring procedures, and the availability of necessary resources. The practice manager has a leading role in implementing and encouraging a supportive culture.

    Notes:

    1. Baker JJ, Baker RW. Health Care Finance: Basic Tools for Nonfinancial Managers, 4th ed. 2014. Burlington, MA: Jones & Bartlett Learning.
    2. Urgent Care Association (UCA). 2017 UCA Benchmarking Report.
    3. Kentucky Administrative Regulations. “Title 902: Cabinet for Health and Family Services Department for Public Health.” Available from: bit.ly/2naAQEz.
    4. UCA.
    5. Craig W. “3 reasons why positive work cultures are more productive.” Forbes. July 25, 2017. Available from: bit.ly/2nQrqOD.
    6. Prakash B. “Patient satisfaction.” Journal of Cutaneous and Aesthetic Surgery, 3(3), 151–155. Available from: bit.ly/2nRyoTu.
    7. Everhart D, Neff D, Al-Amin M, Nogle J, Weech-Maldonado R. “The effects of nurse staffing on hospital financial performance: Competitive versus less competitive markets.” Health Care Management Review, 38(2), 146–155.
    8. Ayers AA. “Cost-effective staffing with medical assistants.” The Journal of Urgent Care Medicine. Available from: bit.ly/2nTg2RW.
    9. Craig.
    10. Everhart.
    11. Corkindale G. “The importance of organizational design and structure.” Harvard Business Review. Feb. 11, 2011. Available from: bit.ly/2mpeLBO.
    Jacquelin Houze

    Written By

    Jacquelin Houze, FACMPE

    Jackie.houze@stelizabeth.com.


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