In any medical organization, the staff is the heart of operations, from direct patient care to billing and collections. So, to keep things running smoothly, you must create an effective and motivated team of employees—whether they report directly to you or another physician—to run the best practice to serve your patients.

Your medical practice's organizational structure provides a blueprint that helps guide the behavior and decision-making of the entire team. Whether your practice is large or small, independently owned, or part of a university or integrated system, establishing a structure that reflects the organization's core values and mission is essential. This organizational structure becomes the mechanism that enables your practice to achieve its clinical mission and thrive financially.

Usually depicted in the familiar organizational chart format, a detailed organizational structure defines personnel needs from the executive leadership level at the top down to the staff level. It should detail all the departments and staff needed to run your practice efficiently.

The process of organization planning includes the following steps:

• Define your leadership structure. Who's guiding the overall organization, and what are the subgroups within it?

• Define each department, its purpose, and the authority and responsibility residing within it.

• Identify the staff roles each department needs to manage its workload.

• Define reporting relationships and scope for the managers and staff in each department.

Reporting relationships help everyone in your practice know which decisions each manager makes and what tasks their teams are responsible for. Establishing and respecting these relationships can help your practice function efficiently. Whether you are in a senior leadership position, a department chair, a manager, or a staff physician, it is important to understand and respect the organization's structure. Everyone on the team fits into the overall business and has a defined set of responsibilities. This division of labor helps the organization do more and speeds up decision-making.

Physicians typically have a clear understanding of their clinical role and their responsibility to the practice and their patients, but don't always have a clear understanding of the business structure. This can have implications that affect how well you work with your direct superior and others in leadership positions.

An effective organizational structure provides a path to work well together and resolve issues. A functional structure supports collaboration while meeting the operational needs of the practice and reflecting its core values.

Developing a staff plan requires considering the work each department will perform and the staffing positions required to do it reliably and efficiently. Consider, for example, some of the variables that determine the size of your billing department:

1. Will it need a manager, or will a lead employee that reports directly to the office manager suffice?

2. What will the daily volume of work be? Will staff need to perform all data entry, submission of claims, processing of patient statements, collections, and accounts receivable, or will some of these responsibilities be off-loaded to an outside agency?

For each administrative function, define the responsibilities and positions required to manage those responsibilities. Complete this process to delineate every department you'll need, from finance and human resources to appointment scheduling and reception.

Once department size and scope have been determined, each department manager can develop job descriptions to define the right team to handle the department's essential tasks and anticipated workload. The job description is an instrument not only to ensure assigned staffing meets department needs, but also to guide managers in selecting the right hire for each position, supporting practice efficiency, and reducing costly staff turnover.

Each of your practice's job descriptions should include:

1. Title and description of the responsibilities of the position.

2. Desired traits, skills, and work styles. For example, a receptionist must be flexible and skillful at interacting with people; a bookkeeper must be precise, have strong numerical skills, and work well independently; supervisors must have strong organizational skills, be able to motivate and guide others, and be motivated by goals.

3. Educational or certification requirements preferred or required.

4. The years of experience preferred or required.

5. The scope of authority and the position that he or she will report to.

To have a successful team, the foundation of clear staff roles comes first. If it's not clear what each person's role is, the result will be confusion and inefficiency at your practice. What's more, when it is not clear who is accountable for what responsibilities, errors are more likely and more difficult to resolve.

Once you've defined the roles you need for success and found the right person for that position, you need to define the expectations and outcomes essential for each position. That's where performance standards come in—as a tool to measure how well your employees perform, whether it is success during a trial onboarding period or during an annual review.

Establishing benchmarks helps supervisors understand when the workload has grown or declined (perhaps with the addition of automation) and necessitates an adjustment to head count.

For example, let's examine key components related to the position of appointment scheduler.

Quantitative dimensions:

• The average number of incoming calls managed per hour

• The number of dropped calls

• The number of patients scheduled each day

• The number of potential new patients converted to an appointment

• The number of patients prepared to make a payment at time of visit

Qualitative dimensions:

• Phones are answered within three rings, and callers will be placed on hold less than 45 seconds.

• Standard greeting: for example, employee will identify practice, welcome the caller, and introduce themselves.

• Information to be collected when scheduling: for example, demographics, insurance, updated address, phone, email.

• Information to be shared when scheduling: policy and payment expectations at time of visit.

• Information to be sent to new patients: new patient information forms or website link.

• Information to be requested of new patients, such as prior medical records.

Performance measures are specific to a practice, job function, skill required, and volume of work expected, as well as the tools provided. Most performance measures are tracked by your computer software and can be accessed by authorized managers. Other data points can be gathered through observation.

Performance reviews, based on performance standards, require planning. A performance review is a written evaluation of an employee's performance over a set period. The review is shared with the employee in a one-on-one interactive conversation. During the review, the employee and his or her direct supervisor, which could be you, discuss areas where that employee excels, where there is room to improve, and goals for the following year. Guide the performance discussion based on the expectations explained on the existing job description.

When you feel that staff members are not meeting performance expectations, you'll want to offer specific objective examples. If you want certain staff members to change what they are doing, develop a performance improvement plan that outlines measurable expectations within a specific time frame and describes how you and others will help. For example, will your practice provide further training or education, additional work tools, or mentoring?

If the employee's performance has been exemplary, the review may provide an opportunity to discuss the possibility of future promotions. It is also the perfect time to get the employee's impression of the practice's overall performance. He or she might have suggestions to increase productivity or provide insight on staff morale.

Performance reviews should never be tabled unless it is unavoidable, in which case they should be rescheduled as soon as possible. Give new employees a written review at the end of an introductory period (eg, 90 days), and then review each employee annually. Pay rate increases are often given during the performance review, but this is not mandatory. Make sure your practice has a clear policy on when raises are given, however, so employees know what to expect.

Communicating consistently and effectively plays a huge role in how employees in any medical setting view management, how important they feel, their motivation, and whether they take ownership of their work and pride in their accomplishments. Again, as the heart of a practice, staff need information and reinforcement to keep things beating in a steady rhythm each day.

One-on-one communication is an important opportunity to build successful relationships with staff. It begins with mutual respect and nurturing. When you give a little attention to individuals and are thoughtful about your actions and word, staff feel valued.

When communicating, remember:

• Verbal communication: Refer to individuals by name during the conversation. Ask for feedback and be generous with giving thanks.

• Nonverbal communication: Your body language sends a message and is an expression of your attitude. Give eye contact and a welcoming gesture, such as a smile or a nod, or a handshake.

• Listening: When someone is talking, give him or her your full attention.

Staff and department meetings are an excellent way to communicate messages to a unified group of people, ensuring the message is clear and consistent and allows for discussion and valuable feedback. It also provides an opportunity to nurture teamwork by raising specific issues that may have emerged, discussing potential solutions, and agreeing on a resolution. This creates buy-in from the very people affected by a situation.

Written agendas help guide the discussion. Establishing a time limit on each agenda item avoids meetings that run over time, which busy staff will appreciate. The meeting should not be just a string of announcements, which can be better handled via email or a bulletin board. Interaction between leaders and staff is what makes meeting valuable for problem-solving and strengthening relationships.

Add value to a meeting by circulating your agenda to supervisors or managers, giving them the opportunity for input. Document action items, assigning a person and a target completion date.

Salary schedules are an important element of the practice structure and a valuable tool to ensure your employees are fairly compensated. It also helps determine your annual budget for staffing, how it is allotted by department, and how it is adjusted annually.

The job description is a guide to setting the pay range for each position according to the education, skill set, experience, and responsibilities required of the position. In addition, supply and demand will influence the going rate for your region. Remember, a position title alone does not dictate the value of the work when gathering information from other practices. Each practice has its own set of requirements, tasks, and responsibilities that can create a wide variance in expectations and pay rates for staff positions.

Once you establish the base pay for a new hire, the next step is to set a criteria and range for further pay increases based on job performance, your value and appreciation of the employee's skills, and contribution to your practice. Certainly, a stellar employee's pay is expected to increase more than that of a mediocre colleague holding the same position.

By designing the salary schedule with a range for each position, you have the liberty to work within that range when increasing wages throughout their department, as well as when hiring new employees.

List each position's grade on knowledge, capabilities, and the amount of responsibility and authority assumed. Create payment levels 1-5 to show an upward shift in pay ranges based on years of experience. Typically, the schedule is reviewed and adjusted each year based on a specific financial measure, such as the Consumer Price Index, or a formula based on several measures.

Pay rates for each organization should be based on its own data analysis. Seek data about pay rates locally and regionally through reliable sources, such as your medical society and medical personnel agencies in your area. Salary.com and similar websites also provide helpful pay data. Local colleges or professional medical staff training schools may have useful data that they are willing to share as well, so reach out for some help. Medscape has many surveys that benefit managers, including a salary study for nurses.

Some of your employees may disclose past salary history. This can be another data point about salary trends in your area, but keep in mind that salary claims from candidates may not be accurate. Your salary analysis will reduce subjective factors when determining pay rates.

Even more important, some state and local governments now forbid asking candidates about their salary history. Before recruiting new employees, be sure you've lined up reliable sources of salary information and know what laws about salary history apply in your area.