I have a CA that has been with me for a very long time. If she left, I would be in big trouble since she runs the front office. While I do not expect her to leave, how do I protect myself in the event that she was suddenly unable to continue her employment?

Every chiropractor lives for the day that he or she has the type of chiropractic assistant (s) that are so professional in the performance of their duties that little, if any, management is necessary. When this dream comes true, the real nightmare begins. What happens if this great employee leaves for another job or becomes disabled? The answer to the question lies in the necessity for a doctor to properly manage all of the jobs in the office.

A doctor is no different than other business owners that delegate responsibility to his or her employees. If you ignore the management of a function, you will pay a tremendous price when the unsupervised employee leaves your employment. You must continuously review the requirements of every job in your practice and identify the knowledge, skills, and abilities that are necessary for each job. The best managers will accomplish this through detailed procedures manuals that they test by performing different jobs in the office using the procedures. This investment of time will pay big dividends when you need to replace an employee unexpectedly.

Am I required to have a written job description for every person that works in my practice?

Yes. The HIPAA laws require that every person that works for a health care provider must have a written job description.This job description is used by the government to determine if the individual has job responsibilities that allow them access to the patient’s clinical records.

My spouse works in my office in an unpaid capacity. Does she need a job description?

Yes. The federal HIPAA requirements apply regardless if the individual is paid or not. Doctors who have unpaid spouses that work in their practice are also required to have written job descriptions.

I have four CAs that work in my office. All of them have been with me for a number of years but one has announced that she will be leaving shortly. Is there anything I should be thinking about before I place the ad for her replacement?

Although no one likes to lose a long term employee, it is an ideal time to take a look at your overall practice and, this job in particular, to see if there is any part of the job you like to change. A vacancy puts you in the best position to evaluate whether the job’s duties and responsibilities should be changed, without being concerned about how the person in the job will feel about your decision. It is easier to redesign a vacant job than one that is filled.

The person who currently has the position may have some responsibilities that you would like to transfer to another person in the office. While you may have felt inhibited from suggesting a change in responsibilities when the current person held the job, now that they are leaving, you have the perfect opportunity to reorganize. In doing so, you may enhance the jobs of other staff members and improve how they feel about their work.

You might also review your previous experiences filling the position. Some questions you might want to consider include:

• Do you really need to fill this job?
• Is there any other way to get this work done without hiring a permanent employee (e.g., temporary help, redistributing duties)?
• Should the job be part-time or full-time?
• Should there be a change in who this individual reports to?
• Should any job duties be changed, eliminated, or expanded?
• Was there anything that worked particularly well, or poorly the last time you filled this job, or other jobs?

Answering these questions can help you:

• Make sure that each person you pay is important and critical to your practice. “We’ve always done it that way” doesn’t mean that you should continue to do it that way. Any vacancy you fill must add value to your practice. Businesses must adapt to survive. By spending some time analyzing your vacancy, you can help your practice adapt and survive.

• Determine if there is something unusual about your turnover rate. Clues to problems you might be having can often be determined if you have open and frank discussions with every person who leaves their job. While these conversations are often difficult, they give you insights about your management style, the work habits of other employees, your compensation, or the requirements of the job itself. These insights can help you avoid mistakes with the next person you recruited for that job.

• Review the methods you have been using to hire employees and identify any changes you should make this time. For example, did your newspaper ad produce too many unqualified applicants last time? Did performance problems crop up after hiring that you wish you had found out about during the interview or during your reference checks?

When you have taken the time to review these questions and are satisfied that the job is designed correctly and needs to be filled, you are in great shape to identify the critical skills and characteristics that you will be looking for in an applicant. There may be a point at which you begin to feel discouraged but, please do not give in to this feeling. If this is the first time you have gone through this process, it is time consuming. It will get easier each time you replace an employee. Going through this process could mean fewer employees to replace in the future.

I am having difficulty finding job candidates from my classified ad. Are there any other sources for chiropractic assistants?

There are many sources for qualified candidates, each with its own advantages and disadvantages.

These sources include:

• The local labor market (which you usually reach with a classified newspaper ad)
• Internal candidates
• Referrals from staff and colleagues
• Employment agencies
and temporary help firms
• Technical schools and colleges
• Your state’s Job Service
• Unsolicited applicants — “walk ins” Newspaper Advertising

Placing an advertisement in the classified section of your local newspaper is perhaps the most common way to recruit. Classified ads can be very effective if you design and write a good ad. A carefully crafted recruitment ad can ensure a good response from people who are qualified and interested. Remember — the effectiveness of a recruitment ad should not be measured simply by the number of applicants it attracts. A good ad attracts qualified and interested applicants. Referrals can be an excellent and inexpensive source of good candidates. One advantage to referrals is that most people will not make a referral unless they believe the person they are referring is a good candidate. To some extent, they are staking their reputation on the referral. Therefore, the person doing the referring serves as your screening mechanism.

Your own employees can be particularly good referral sources. Again, they are staking their reputations on their referrals, so the quality of the referral is likely to be high. It may also be worthwhile to make a few phone calls to your chiropractic colleagues. They may know qualified people who have contacted them for positions. Of course, you must be careful to consider the sources of referrals — never substitute anyone else’s judgment for your own. Make sure you carefully screen referred candidates before you make a decision.

Employment agencies and temporary firms. These organizations can provide you with pre-screened candidates for a fee. Because employment agencies specialize in placing candidates, they can save you a lot of work. But, of course, you will pay for this help. Temporary firms can also be a source of good candidates or even permanent hires. “Temps” are the fastest-growing segment of the labor market. Many organizations use temporary firms as a short-term solution — for a day, a week, a month, or as long as needed. If this match works, the hiring company can hire the “temp” permanently. Some temporary firms offer a “temp to hire” option, which can be an excellent low-risk way to try out a new employee. Once again, the temporary firm does the screening, selecting, and provides you with an employee. Typically, you will pay a higher rate for a temp than if you hired the employee yourself in order to cover the temporary firm’s costs and profit. However, you do not have to pay for benefits while the person is on the temporary agency payroll.

Be cautious when considering hiring individuals from either one of these sources. It is rare that they can offer you candidateswith direct work experience in a chiropractic office. While their individuals may have insurance company or medical practice experience, do not expect them to blend in immediately in your office. Every chiropractor approaches patients in a unique manner and some training will always be necessary.

Technical schools and colleges. Depending on the type of position you must fill, technical programs (especially the chiropractic technician programs) and colleges can be excellent sources of candidates. Colleges and technical schools offer elaborate placement services. They work hard to place their graduates and will cooperate with you to refer qualified candidates in fields such as secretarial/clerical work, bookkeeping and accounting, general business, and health care. Most placement offices will be happy to discuss their programs with you to find the best employment match. These people can be useful, low-cost employment resources.

Job Service. Your local state Job Service office is in the business of matching qualified people with jobs. This is often an overlooked resource. You simply place an order with Job Service, and they provide you with pre-screened, qualified candidates at no cost. Of course, you are not under any obligation to hire candidates Job Service refers to you. Job Service offices are listed in the “Government” section of the telephone directory.

Older Worker Placement. There are a number of organizations that place older workers who may have retired but still want to work, perhaps, part-time. These people can provide a busy practice with seasoned and reliable employees. These organizations (e.g., Over 55 Employment Service) are also listed in the yellow pages.

Walk-ins. You should also keep a file of unsolicited applications from people who write, call, or drop by. It is possible that a patient may indicate an interest in working in a chiropractic office. Even if you don’t have a vacancy when they contact you, you may want to contact them later. After all, if a person is motivated and aggressive enough to “cold call” you, they could make a good employee. When you have an opening, review your applicant file and contact anyone who seems qualified.

I am advertising for a chiropractic assistant for the first time. The only problem is that I have never written an ad before. Can you offer me any advice?

The most important part is the help wanted ad is the headline. A person scanning the employment ads bases their decision on whether to read the body of an ad only if the headline has grabbed their attention. If they skip over your headline, your ad missed its mark. Therefore, an eye-catching headline is a key element to an effective advertisement — it is the bait that will attract your catch.

Many readers only skim the classifieds to see if anything interests them. They may have a job, but would not mind a change if the right situation caught their eye. Therefore, your headline must draw their attention. Several points to keep in mind:

• Five times as many people read the headline as read the ad.
• People want “big” jobs, not small jobs. Your headline should be bold and big — use distinctive and large type. Larger ads are more expensive, but also usually attract more candidates. At the absolute minimum, make sure to add plenty of white space (empty lines) around your headline.
• Be descriptive so candidates can relate to the ad.
• Don’t exclude someone who could be qualified. The more requirements you put in an ad, the more people you screen out. Don’t advertise for a “bookkeeper” when you will hire a clerical assistant who can do some bookkeeping.
• Sub headlines can be useful. You might want to list “chiropractic office” under the headline “receptionist.” This will help attract interested candidates. For instance, you could attract candidates who have enjoyed good health because of chiropractic. Hiring a person who is already enthusiastic about chiropractic would be a big asset.

Running an ad for a number of weeks can get expensive. Can I economize by leaving out some of the details about the job?

Your ad does not have to tell the reader everything about the job. It should provide enough information to interest and attract qualified applicants. To do this, the ad should inform, create interest, allow the candidates to screen themselves in or out based on the job’s description and requirements, and enable the applicant to respond easily.

If the person is intrigued by the headline, you have a chance to further their interest based on the text of your ad. The biggest mistake made by some is to try to save a little money at the expense of providing a full description of the opportunity. Here are the key elements for the text of a help wanted ad:

The opening. The opening section of the ad typically identifies the employer, the job title, and the general location of the job. For example: ‘Smith Chiropractic, located across from the Hillside Mall is seeking an energetic individual to be our Office Manager.’

Job duties. Briefly summarize the job, providing enough detail to enable the reader to determine if he or she should apply. Use action words and active voice — for example:

• “You will direct the day-to-day activities of the office’s staff.”
• “This person will greet patients and schedule appointments.”
• “You will be responsible for submitting and collecting our insurance claims.”

Do not oversell the position. Doing so is dangerous and counterproductive because it can attract people who are not really suited for the job. This will end up wasting your time as you have to interview individuals who are not fully qualified and can be disastrous if you hire someone who is not really suited for the job. If your vacancy is for a transcriptionist, state that in the ad; do not try to make it sound like the person will be in charge of the entire office.

Job requirements. Concisely identify the primary qualifications and skills you are seeking, so applicants can decide if they’re qualified and respond with their qualifications in a resume or application. For example, you may be looking for someone with experience in a chiropractic or medical office who has handled scheduling, filed insurance claims, and billed patients. You also want this person to be organized and detail-oriented, to have good people skills, and to possess an outgoing personality. If these are the skills you absolutely must have, list them in the ad.

Some chiropractors do not require their job applicants to fill out an application or submit a resume before they interview a candidate. While this is fine if you have an unlimited amount of time for interviews, if can be a highly inefficient way to screen candidates. If you know the skills you must have in a candidate, it is pointless to interview individuals who do not have those skills. By listing the skills required for the job in the body of the ad, you are helping yourself eliminate individuals from applying who are not qualified.

How to apply. This is a critical part of the ad because you want to be able to encourage a large response without committing yourself to never ending interviews. Here are several ways to handle responses:

• If you think your ad will draw a limited response and you are looking for specific skills, you may simply ask applicants to call someone in your office. You can then screen the applicant on the phone, and decide whether to conduct an interview. This can be an excellent way to screen candidates for a scheduling and/or receptionist job, where telephone skills are critical. When assigning this job to someone in the office, be sure that you photocopy a list of the skills that you are seeking. As candidates call in, have your staff person “check off” the skills as the candidate goes over their experience.

• You can state that applications are being accepted on certain days and times at your office. This can be a very fast way to fill a vacancy. It allows you to review qualifications quickly (even immediately), and then make interview arrangements. On the other hand, if you attract too many applicants, this can disrupt your office and create a lot of work. If you use this format, it is best to request applicants to come on your day off or when you are least busy.

• You can ask applicants to submit a resume. This is not as fast as telephone calls or office visits, but it gives you more control over how to screen the responses. As you receive the mail, you can review the background and experience of the individuals who apply and decide whom to invite for an interview. This approach is particularly useful for an office manager’s position when you want to be sure that the individual has the experience to handle the position.

Should I tell define the application process in the ad or leave it up to the individual to decide how they will apply?

This is a critical part of the ad. Your application process should be clearly-stated; it should be efficient for you and “user-friendly” for applicants. Your first thought might be to ask for a resume. However, ask yourself if you are filling the kind of position where most applicants will have resumes. If you are looking for a receptionist, the answer is probably no. If you expect a resume for a position like this, you may limit the response. On the other hand, If you’re looking for an office manager, you probably should expect a resume. Here are several ways to handle responses:

• If you think your ad will draw a limited response and you are looking for specific skills, you may simply ask applicants to call someone in your office. You can then screen the applicant on the phone, and decide whether to conduct an interview. This could be an excellent way to screen candidates for a scheduling and/or receptionist job, where telephone skills are critical. When assigning this job to someone in the office, be sure that you photocopy a list of the skills that you are seeking. As candidates call in, have your staff person “check off” the skills as the candidate goes over their experience.

• In your ad ask applicants to drop by your office on certain days and times to fill out an application. This can be a very fast way to fill a vacancy. You can review qualifications quickly (even immediately), and then make interview arrangements. On the other hand, if you attract too many applicants, this can disrupt your office and create a lot of work. If you use this format, it is best to request applicants to come on your day off or when you are least busy.

• As mentioned above, you can ask applicants to submit a resume. This usually isn’t as fast as telephone calls or office visits, but it gives you more control over how to screen the responses. As you receive the mail, you can review the background and experience of the individuals who apply and decide whom to invite for an interview.

Regardless of the method you prefer, your ad must clearly state how candidates must proceed. If you have an application deadline, include it. The best-written ads are useless unless applicants know how to answer them.

I have tried advertising for a chiropractic assistant in the big paper but my ad seems to get lost. What other sources might I consider?

Newspaper advertising does not have to be limited to the daily newspaper. Suburban papers, your local shopper are also good resources. These local publications can be inexpensive and surprisingly good sources of employment advertising. If you are seeking a part-timer where experience is not a big factor, bulletin boards at your church or grocery store can be effective.

I hate interviewing because most of the people I interview turn out to be completely unsuitable for the job. What techniques can I use to increase the quality of the people I bring in for interviews?

The most effective way to make the interview process more productive is to phone screen candidates before you invite them in for an interview. You can learn a lot over the telephone, without investing much of your, or the candidate’s, time and energy. Your goal in the conversation is to ask a few questions that will give you a good idea of whether you want to meet this applicant in person. Try to focus on “knock out” questions that will rule the person out. For example:

• Listen to the person’s conversational style. If they cannot handle a simple conversation with you, they probably will not be able to handle complex conversations with patients.

• Briefly discuss their experience to determine if they have accurately summarized their background on their application or resume. Some candidates will look at your ad and try to improve their chances of getting the job by listing experience on their application that they do not really have. If you ask them to describe their experience, and not just the length of time they have worked at a job, you will get a much better feel for the quality of that experience.

• Ask the candidate if they have performed the specific tasks your job requires. Find out if they prepared billing statements or simply mailed them out. Find out if they worked in a busy office as a receptionist or just answered the telephone occasionally when other people were busy.

• Find out why the applicants left their previous jobs and why they want to change jobs now. Be alert for the ever-present “personality conflict” and explore exactly what that means. You don’t want to hire a ticking time bomb who has personality conflicts with almost everyone.

• Find out what aspects of the candidate’s current job he/she likes best and least, and then match this answer to your job. Ask applicants to describe what they want in their next job. Make sure the days and hours of work are acceptable. If there is a mismatch in any of these areas, you’ve probably eliminated a candidate.

Remember, you completely control this process. The minute you find something that rules the person out from an interview, you can end the interview. The most courteous way of doing this is to state, ‘I really appreciate the time you have given me. I have quite a number of phone calls to make. As soon as I complete them I will be inviting the top candidates in for another interview. I sure hope you are one of those selected. Thanks again for your time.’

I am a little embarrassed to admit it but, I cannot seem to find the right people for jobs in my office. They are all nice enough but I have not had success in finding people that can really do the job. What am I doing wrong?

More than likely the problem can be traced to poor interviewing. Don’t feel bad: interviewing people is a skill that needs time and experience to develop. The next time you interview a person remember that a job interview has two objectives. The first is to provide you with enough information to decide if a match exists between the job’s requirements and the person’s knowledge, skills, abilities, and interests. The second is to provide the candidate with enough information to help her decide if a match exists.

There are three basic steps to a good interview:

1) Plan the interview
2) Conduct the interview
3) Analyze the interview results

Why is planning an interview important?

This is a critical stage that many small business owners overlook; you can not have a good interview unless you are prepared. You must decide what you need to cover in the interview, what information you need to collect, and how you are going to evaluate it. Your focus should be on the knowledge, skills, abilities, and characteristics the job requires.

During the interview, you will ask questions that will help you decide which candidate best meets this profile. You must explore the applicant’s work experience, education, personality, job interests, and anything else that will help you determine whether this candidate is a good match for your job.

How do you do this? The key to an effective interview is to ask a series of predetermined questions that enable the candidate to describe how his or her background has prepared them for your job. Virtually all of the research on personnel selection has reached one basic conclusion:

THE BEST PREDICTOR OF FUTURE SUCCESS IS PAST SUCCESS

If a candidate has successfully handled receptionist and scheduling duties in a busy office, they should be able to competently handle the same duties in your office. If you are filling a clerical position, the person who has successfully performed these duties in another setting will generally be one of your best candidates.

Your questions should encourage the candidates to describe actual experiences that relate to those they will encounter in your office. You should develop these questions beforehand. Another good technique is to prepare a checklist that outlines what you will cover in the interview and lists your questions. You can use this checklist during the interview and note the candidate’s answers to your questions.

Can you give me some tips on conducting an interview?

There is no “best way” to conduct an interview. You should develop an approach that is professional, fits your personality,and lets you obtain the information you need. Here is one widely-used interview model.

Introduction and greeting

• Introduce yourself.

• Ask if the applicant would like coffee, juice, or a soft drink.

• Make some introductory small talk if you feel comfortable doing so. Small talk helps the candidate relax and increases the likelihood that they will open up to you.

• Briefly describe the job, its requirements, its duties, work days and hours, etc. It is possible that the individual may not have much knowledge about the chiropractic profession, take a couple of minutes to describe a chiropractor’s work and the type of patients you see.

• Describe the type of employee you are looking for so the applicant can relate their experience and skills to your needs. If you have a firm salary in mind, tell the applicant how much she/he will earn and what benefits you offer. By offering all of this information, you are giving the candidate every opportunity to sell themselves to you without the possibility of misinterpreting the duties and responsibilities of the job.

Ask questions

• Ask structured questions. Keep in mind that individuals respond differently to questions. While some will immediately give a full and complete answer, other people like to answer more slowly. You should not immediately jump to the next question on your list as soon as the candidate finishes speaking. Instead, allow a few seconds to go by in case they have additional information they would like to share with you.

Ask follow-up questions.

Allow the candidate to ask questions

• Give the applicant time to ask questions about the job or your practice. Provide honest answers, even if you may discourage the applicant. Remember — it is far better for the candidate to decide that there is not a match, now, rather than for you to find this out after you hire them. You obviously want to put your practice and the job in the best light, but be realistic.

• The type and quality of each applicant’s questions also gives you more insight to this person. Is she/he asking good questions? Have they understood what you have explained about your practice and the job?

Wrap up and outline what will happen after the interview

• Explain where you are in the hiring process by saying something like: ‘I still have to interview several candidates before I make a decision’.

• Explain when you expect to complete your interviewing.

• Ask when the person would be available to start if they are selected.

How does a spouse working for a doctor affect the spouse’s self esteem?

When practices are started, it can take a long time to develop a large patient base and the financial strain on a doctor can be enormous. It is not unusual for a doctor to question why he or she chose this particular career path. Doctors who have pride in their skills wrongly assume that a lack of patients means that they do not have adequate clinical skills. They just do not realize that in an era of managed care they are competing with a large number of doctors for a fixed pool of patients. During this period, the spouse doing the administrative work is in an excellent position to reinforce the self esteem of the doctor.

As experience gives rise to an increase in patient volume, the roles can become reversed. As the practice becomes increasingly busy, the demands of patients and insurance companies increase the administrative stress and it can be the spouse doing the administrative work who needs a morale boost. There is a tendency to assume that the administrative side of the practice runs itself and that only the chiropractor’s life is hectic and stressful. This is simply not true. The practice that is easy to manage with 30 patients per week is exponentially more difficult than the one with 30 patients per day. To make the office relationship work, the chiropractor must acknowledge the complex environment which the spouse manages.

This mutually supportive relationship is easy to describe on paper, but far more difficult in real life. The qualities that make an individual attractive as a marriage partner are not the same as those that make a business partnership successful.

Constantly reminding yourself of this fact will be of great help if the business partnership does not work. It is the uniqueness of an individual which makes them attractive to another person. Sharing all day, every day, with the same person can make the spouse less appealing. This can be greatly exacerbated if the administrative spouse is not challenged by the work and only accepted the role because of the family’s financial situation.

If this has happened, or is happening to you, do not be disheartened. You should feel fortunate that you recognized the situation for what it is, before the demands of the practice impede or destroy your personal relationship.

It is not a failure for the spouse with administrative responsibilities to decide to seek a similar position with a different company. In fact, if both parties recognize that they have unique talents that just do not happen to blend in the business world, this knowledge may allow the other parts of their lives to flourish.

When couples work successfully together, they have developed a system of mutual support recognizing that the skills of one party supplement and enhance the skills of the other. Each has to make a special effort not to take the other for granted. Even though they are sharing their lives 24 hours a day, they understand the importance of creating time to communicate about business problems separate from their personal lives. Long term spousal working relationships are rare, but when they work well the practice is a truly enjoyable place to work

I do not currently pay my spouse for her work in my practice and, quite frankly, it is a source of tension between us. Does payment to a spouse matter since all of the money “goes into the same pot”?

When a practice is started there is only one problem with money - there is never enough of it. Paying school loans, the expenses of the practice, and trying to find enough left over for the other necessities of life is a crisis that lasts until the number of patients rises to a profitable level. For those couples who choose to work together, this time in their professional lives helps them develop business skills that will last a lifetime.

Generally, the scarcity of disposable income requires that every expense be kept to a minimum, which usually means that the administrative spouse receives little, if any, compensation. Both the husband and wife share the income of the practice after all of the other expenses are paid. While this may seem to make perfect sense as a way to keep overhead to an absolute minimum, this strategy sometimes overlooks a key economic argument. If the administrative spouse is talented enough to manage the complexities of a chiropractic office, this individual could be using their talents in another business and potentially earning an income large enough to offset the cost of hiring a qualified person to run the office. The economic arguments are immaterial if the desire of the couple is to work together. But as the financial situation of a practice improves, you may want to change the way income is distributed within the family.

The common practice is for the chiropractor to declare all of the income. This gives the impression that the chiropractor is the “bread winner” in the family. While the chiropractic spouse makes a very important contribution, allocating all of the income to this individual may severely impact the self esteem of the administrative spouse. It may be unfortunate, but society tells us that our paychecks are a way of measuring the worth of our professional lives. If a person never receives a paycheck, they may begin to wonder about their real value to the practice.

The chiropractic spouse may have no idea how important a paycheck is to their spouse. Receiving one may not only validate their contributions to the practice, but also inspire them to make more of a contribution to the development of the practice. Even when income is tight, this problem can be addressed by “paying” the administrative spouse a portion of whatever profits the practice produces. What about the argument that by not paying an individual, the family saves by not having to pay social security taxes? This is a short sighted argument. Social security taxes are used to fund the government’s retirement system. Benefits are based on a person’s contributions to the system. By not contributing, the practice could really be hurting the retirement income of the spouse doing the practice’s administrative work.

How do you divide authority when one spouse is the chiropractic and the other manages the office?

Acknowledging and respecting the authority of an individual to do their job is never more important than when your spouse is the person responsible for the work. The following are guidelines that can help:

• Both spouses need to respect the work of the other.
• Topics of a personal nature should never be discussed in front of patients or staff. This is especially true if it is a personal problem.
• The compensation of either spouse should never be discussed with staff members.
• The responsibilities of each staff person should be clearly understood.
• No staff member, including the administrative spouse, should ever tell a patient that they disagree with a clinical decision made by the doctor.
• If the doctor disagrees with a decision made by the spouse, their disagreement should be discussed privately and, only the decision should be discussed with other staff members or the patient.
• The standard for doing a job should be the same regardless of who is responsible for doing the job. If a spouse is not expected to perform at the same level as other staff members, you will see morale problems with other members of the staff.

My staff has been with me for a number of years but they never seem to get any better at their jobs. What can I do to change this?

Training is too often overlooked by businesses, especially small businesses. That is too bad, because training is critical to the success of each employee and to the business itself. No matter how good your staff is, they must always be trying to upgrade their knowledge and skills.

To identify training needs of your staff, you first need to identify the critical knowledge and skills your practice and staff need to succeed. These could include customer service, patient relations, computer skills, record-keeping, telephone skills, supervision, billing and collecting, office management, or the specific skills required to process worker’s compensation, Medicare, or Medical Assistance claims. Once you have decided that a staff member needs training, you must decide what kind of formal training to provide.

Formal training includes seminars, conferences, classroom training, and even bringing a trainer to your office for in-service programs. Classroom training such as seminars work well for specific topics such as Medicare rules and worker’s compensation procedures, customer service, supervision, patient relations, accounting, receivables collections, and computer skills. Formal training can be provided by sources such as:

• The WCA
• Local colleges and universities, which may offer short courses or seminars on topics such as supervision, financial management, computer skills, etc.
• Training organizations which offer one-day programs on topics such as customer service, dealing with difficult people, office management, etc. These programs are offered periodically in different cities.
• Correspondence programs which allow the trainee to learn at their own pace, with video or audio tapes, and workbooks.

We have a rather large administrative staff that works in a four doctor office. How can we reduce turnover by making our employee’s jobs more interesting?

When a larger practice provides some type of career development to its employees it can decrease turnover and greatly improve the overall efficiency of the office. Career development is more than training — it involves giving employees other chances to grow and advance. Possible career development opportunities include:

• Cross-training Providing your staff with opportunities to learn their co-workers’ jobs. This can be a “win-win” situation, because it provides your practice with trained back-up support, and expands your employee’s skills and abilities.

• Job rotation Periodically shifting job duties among your staff. While this can be a somewhat radical step that requires training and may be inefficient in the short run, it can revitalize employees who have become stale and bored.

• Promotion from within before hiring from the outside, look to your own staff. Are there any talented people who could benefit, financially and otherwise, by moving into a vacancy? Internal promotion can help you by filling a job with someone who already knows your business, and it can also help the promoted staff member. It also lets your people know that you want to help them professionally.

How can we motivate our staff to perform at a higher level?

Here are a few ways to motivate your staff:

Let your staff members be responsible for work that they can call their own. This gives them the “ownership” and responsibility they want. Most people who start a job want to finish it and see the results of their work. For example, you can make sure that the person who sends the bills out also handles payments when they come in and deals with late payments. You can make sure that the person who greets a patient also escorts them to the treatment room and then schedules their next appointment. These may be small steps, but they can help your employees feel that they are in charge of their own work.

Make sure that your people understand and appreciate how important their work is. Most people want to do important jobs. In a small practice, everyone’s job is critical to the practice’s success. It is your responsibility to make sure every employee understands their role and how their work fits into the success of the practice.

Praise good performance.

Employees complain about a lot of things, but very few complain that they are being praised too much. When someone does a good job, or gives excellent service, they should be recognized. This makes your staff members feel appreciated and important and it also shows them that good performance will be rewarded.

Formal award programs (employee of the month, the quarter, the year, etc.) can also be good ways to recognize excellent performance as well as special training or increased responsibility. Recognize good performance even if you do not reward the employee with money.

Give your staff the independence they need to perform well. Talented people want the freedom to do their jobs well. Staff members should be oriented and trained, given performance standards, and then be allowed to do their jobs. It is inefficient and frustrating for the boss to constantly check and second-guess his or her employees. If this kind of supervision is necessary, then some other kind of action is needed to improve performance. While managers and supervisors need to know how well their staff members are doing, try not to “micro-manage” your people.

Encourage your staff to suggest ways to do their jobs better. Suggestions like these can make your practice operate better. A large part of Total Quality Management is “empowering” employees to find ways to do their jobs better. Even without embarking on a TQM program, you can encourage your employees to find ways to improve your operations. Your employees can be a great source of ideas to provide better service to your patients.

I think my employees know what I think of their performance. Are performance appraisals really necessary?

Unfortunately, the words “performance appraisal” usually strike fear in the hearts of both chiropractors and their employees. Performance appraisals (evaluations) create images of awkward and negative discussions or filling out pieces of paper that do not have much real meaning.

Performance appraisal does not have to be that way. First, it is important to understand that performance evaluation is a process, not a piece of paper. Performance evaluation is nothing more and nothing less than a chance for the boss and the employee to honestly discuss performance. A performance appraisal does not have to be in writing, although written appraisals help to avoid misunderstandings. However, no piece of paper can take the place of frequent and open communication between the practice owner and the staff member.

Whether appraisals are written or verbal, appraisal sessions should be conducted on a regularly scheduled basis. Most are done annually except for newer employees where you want to give them feedback on a more routine basis. In addition to formal review sessions, it is important to briefly discuss performance informally as often as possible. These two minute sessions can occur whenever you notice a small item that needs correction. Staying on top of small problems can prevent them from turning into large ones. (Taking a minute to tell someone they have performed well is also an excellent practice.)

If you have done a good job setting expectations, evaluation sessions will be easier and more productive because the staff member should already know how he or she is doing. What is the best way to handle performance problems?

Performance problems do more than create extra work for a practice. They sap the positive energy of a practice and can affect the morale of all of the employees. Dealing with performance problems quickly is clearly the best alternative but also the most challenging, as it can be difficult to confront the employee. It is important to keep in mind that while a performance problem may be hurting the practice, in the final analysis, it is the employee’s problem, not yours. The employee must be committed to solving the performance problem or the situation will never improve.

In dealing with a true performance problem, it is very important to focus on the specific problem — the gap between actual performance and expected performance. Saying “your attitude needs to be improved,” is not nearly as useful as saying, “you must mail patient statements no later than the 10th of the month.” The office manager or doctor and the employee must identify and discuss each problem, agree that improvement is needed, and jointly decide how to correct the problem.

Corrective actions could include:

• Training, if the problem is caused by a lack of skill or knowledge (a “can’t do” problem);
• More specific procedures or guidance, if the employee is unsure how to do their job correctly;
• More intensive supervision (usually for a short time only), if the employee needs more guidance;
• Reassignment, if you think the employee can do a good job in another position. Be careful, however, that you do not just transfer the problem into another job because you don’t want to deal with the problem directly.

If dismissal is a possibility, make this clear. Although firing firing an employee is a very serious step and will usually be the last resort, your employee should clearly know what is at stake.

I have an employee that does her work quite well, but is always late. I would hate to lose her. How do I proceed?

Discipline problems are often different from performance problems and require a different approach, at least at first. Some common discipline problems include poor attendance, lateness, or unacceptable on-the-job behavior.

Discipline problems almost always affect performance or you would not be concerned about them. However, many discipline problems are handled differently from performance problems. For example, sending out patient statements late is a performance problem that can be corrected through discussion and feedback. Any type of insurance fraud, on the other hand, is a discipline problem that calls for immediate dismissal. Some discipline problems should not necessarily result in immediate firing. For example, poor attendance, tardiness, and too much socializing on the job are problems that can be corrected, especially if the employee is a good performer in general. How do you deal with discipline problems? Here is one step-by-step approach:

• Decide how serious the problem is. Is this a major problem (insurance fraud, insubordination or disruptive behavior) or a minor problem (occasional tardiness or long lunches)? How long has it been occurring, how often does it occur, how is the problem affecting the employee’s performance, and what kind of performance history does the employee have?

• Discuss the problem with the employee. Get their side of the story. Find out if there are any valid reasons for the problem (for example, are child care problems causing tardiness or attendance problems?). Do not pry, but do give your employee the chance to explain and give you all the information you need. There might be an easy answer, such as allowing the employee to change their work hours.

• If this does not work, take firm action to deal with the problem. This could range from a verbal warning to dismissal.

Keep in mind that how you handle a discipline problem will send a message to your other employees. Your actions should be consistent with how you have handled situations like this in the past, should “fit the crime”, should be timely, should be fair, should focus on correction rather than punishment, and should put the interests of your practice before the interests of the person.

How often should I discuss compensation with a new associate once they are hired?

Money should be discussed frequently. When the initial deal is struck, neither party is certain if the compensation agreed to will meet their individual needs. If the associate is successful at building referral relationships, they will expect to be rewarded for their efforts. On the other hand, if they are not successful, you may wish to make modifications to the original agreement. For the first six months, the revenue being produced by the associate should be discussed every 1 - 2 weeks. For the balance of the year, monthly discussions should be held. On a long term basis, most successful relationships discuss financial aspects of the business on a monthly basis, although some find that a quarterly schedule is more appropriate for their needs.

I have tried absolutely everything to help an employee but her performance simply has not improved. I have to fire her and want to know the best way to do it. Can you help me?

Sooner or later, every employer must fire someone who is not performing at an acceptable level. Even when you have done all the right things, some people just refuse to do a job the way it needs to be done. Make no mistake, firing an employee is always difficult. This is especially true if the employee is trying hard, needs the job, or is well-liked. Nevertheless, if firing is called for, you must act. If you do not, you are not serving the needs of your practice, your staff, or even the employee. The situation will only get worse and it will eventually affect your entire practice.

How do you fire someone? Unfortunately, there is really no good way to fire an employee. However, here are some suggestions:

• Do not make the dismissal a surprise. Performance problems usually do not crop up overnight. If you have done your job, you have: put the employee on notice that there is a problem, tried to help them deal with it, and have given them feedback. The employee should already know that he or she is not meeting your expectations, and have been warned that they could be fired.

• Document the reasons for dismissal. While you don’t need a lot of paperwork, you should make some record of why and how the dismissal occurred. For example, document the dates of performance problems and the dates you discussed the problem(s) with the employee. This information can be critical if the employee tries to sue on the basis of wrongful discharge or discrimination. Be especially careful if you fire a member of a minority group, a woman, a person with a disability, or a person over the age of 40. These people are protected by federal and state laws that prohibit discrimination.

• Deliver the news as objectively and factually as possible; focus on specific work behaviors. Do not dwell on vague traits such as “attitude” or “initiative.” Instead, identify specific incidents where the employee did not meet your expectations. Point out steps you have both taken to correct the problem.

• Be firm. You have already given the employee a chance to improve. This is not the time to have a lengthy discussion of performance, give in to appeals for more time, or give another chance.

• Be prepared for anything. Being fired can be an emotional and humiliating experience. A fired employee might cry, become angry, or even become violent. Think through how you will deal with these situations.

• Concisely provide important information the employee needs to know. For example, tell the person when the dismissal will be effective, whether you will provide severance pay, what kind of reference will you give the ex-employee, and how will you collect office keys and other property.

• If you can, try to leave the person with something positive. In many cases, the problem is not a poor employee, it is a poor job match. Try to accentuate any positives you can come up with. If you are willing to give a good reference, emphasize this.

• Talk to the rest of the staff. A firing can be difficult not only for the person fired, but for the rest of the staff. They might be wondering if they are next. Talk to them, briefly explain what happened (without getting too specific), and assure them that good performers have nothing to worry about.

Although your employees want more from their jobs than money, compensation is a critical part of attracting and retaining talented people. Compensation is also a big part of the total cost of operating a chiropractic practice. Therefore, you must pay enough to hire and keep talented people but not so much as to risk the success of your practice.

Unless you pay minimum wage, deciding how much to pay your employees involves judgment. Compensation is more than matching what other doctors pay their staffs. Although this is an important part of setting base pay, your pay practices should also:

• Pay no more than what is required to attract, retain and motivate talented employees.
• Be viewed as fair by your employees.
• Reward good performance, and reinforce your practice’s goals and your staff’s performance standards.
• Comply with federal and state laws.

The factors you should consider when setting base pay rates are:

• The local market pay rate for each job;
• The responsibilities of the job;
• The experience, skills, and qualifications of the person in the job;
• The benefits you provide;
• Whether your staff members should be paid hourly rates or annual salaries.

WCA members have access to the chiropractic assistant salary surveys that are conducted on an annual basis. For more specific information about compensation in a specific city, a doctor has additional resources that can be utilized. The first is to request a survey from the local chamber of commerce. The second is to scan the employment section of the Sunday classifieds. Finally, the internet also has salary data, especially for major cities.

Surveys will give you salary ranges — low to high. You can then decide if you want to pay at the bottom, in the middle, or at the top of each job’s range. Keep in mind that paying at the low end of the market may save money in the short run, but it can discourage well-qualified people from accepting job offers. Low pay can also cause dissatisfaction and turnover among the people you do hire. You may be willing to accept these problems to keep payroll costs down.

Benefits should also play a big role in setting the pay for a job. If your practice provides generous benefits (health plan, retirement, sick and vacation leave, life insurance, etc.) you can probably pay lower wages. You may not want to be above the market in both base pay and benefits. If you do provide good benefits, make sure your recruits and employees know this. To some people (employees with young children, for example) benefits, such as health insurance, can be more important than base pay.

How often should I give my employees a raise?

An important part of any pay system is providing employees with the chance to increase their earnings. You should review compensation periodically. Most businesses do so annually, quite often along with the annual performance reviews. Why should you consider raising pay? Here are several reasons:

• To keep your staff “even” with the cost of living
• To reward good performance
• To recognize new responsibilities and duties
• To retain experienced staff

Cost of living If you are paying your people fairly, you have to consider what effect the cost of living is having on their wages. It’s not fair (and does not make good business sense) to keep wages constant for good employees while inflation is eating away at their buying power. If the cost-of-living is going up, you should consider raising wages to keep your people even, as long as they are performing well and you can afford pay raises. You may want to do this for everyone at one time, or include this in your annual performance and salary reviews.

Performance If possible, pay raises should also be linked to performance. In addition to cost-of-living adjustments, you should consider increasing the pay of employees whose performance is improving. These staff members are becoming more valuable to your practice. Again, this decision can be made at the annual review. Of course, if a person is not performing, they should not get a raise.

Experience Many organizations also pay for experience to retain employees who become more valuable as they gain experience. Why pay someone more for simply lasting a long time? One reason is to ensure that good performers stay with your practice.

New responsibilities If you give an employee new duties and responsibilities, they become more valuable and they should compensated accordingly. You can increase pay immediately or after a probation period. Whatever approach you take, make sure you pay the person competitively for the new duties. If you do not, you may save money in the short run; but, in the long run, the job may be done poorly or you may lose the person.

State or federal laws If the federal or state government increases the minimum wage, you must match this increase for any minimum wage employees.

How do I decide how much of an increase to give my employees?

Except for minimum wage increases, pay raise decisions involve judgment. To decide if an employee deserves a pay increase, you must assess how important each of the above factors — performance, new duties, and seniority — is to you and your practice. Then you must analyze each employee to determine if they deserve a raise and, if so, how much. These are usually individual decisions based on each employee’s performance, experience, and skills.

If your practice is not doing well financially, you may not be able to afford pay increases despite the above factors. In this case, you should be truthful with your staff and agree to reconsider when your financial condition improves. This could be a powerful motivator for your staff to work hard to attract new patients and keep current patients. However, if you have decided to give a raise, you must decide what kind of increase to award an individual.

There are two basic ways to raise wages - increase base pay or award one-time payments (usually bonuses). Both approaches can be effective, but one-time bonuses are becoming more common because:

• Bonuses have a larger immediate impact (a $500 bonus may seem like more money than a $.25/hour pay raise, even though they are really the same amounts).
• A one-time bonus is more flexible — it doesn’t increase base pay or commit you beyond the current period or bonus amount.

On the other hand, cost-of-living increases are usually percentage increases to base pay, because the cost of living probably will not go down, and you are trying to keep your employee’s earnings even with inflation. Instead of giving cost-of-living and performance/experience raises separately, you may want to bundle them up into one package and provide them at the same time. A two percent cost-of-living raise combined with a $500 bonus can have more impact than giving the raises separately at different times.

To what degree should I involve my associate in hiring decisions?

When there is more than one doctor in a practice, the chiropractic assistants must be able to work well with each of the doctor’s unique professional and personnel styles. If only one doctor is responsible for hiring, problems will occur unless that doctor is sensitive to the preferences and requirements of other doctors in the practice. If the needs of everyone are not considered, the hiring doctor will have the tendency to view the skills of the applicant based on his or her own needs. Once that chiropractic assistant is hired, other doctors in the office may discover they simply are not comfortable working with the individual. It could be a small irritation, such as not understanding the person’s sense of humor, or a more serious problem relating the individual’s ability to meet the health care needs of patients. In either case, while one doctor may be completely satisfied with the person’s performance, another doctor may feel the desire to fire the person on the spot.

A solution is to have each doctor participate in the hiring process and agree on the individual before he or she is hired. This works well if both doctors enjoy the process of interviewing candidates, but suffers when interviewing is done by a single individual. If interviewing is done by only one of the doctors, the evaluation criteria should be agreed to in advance. At a minimum, this should include:

- what job responsibilities the person will have
- previous education or experience required to do the job
- the kind of personality that is most suitable for the position
- who the person will report to on a day to day basis

While the preliminary selection might be made based on a set of agreeable qualifications, before a final decision is made, all of the other doctors should meet the candidate before she is offered the job. In that way, everyone feels that they have had the opportunity to contribute to the hiring decision. If it turns out that there is absolutely no “chemistry”, a bad decision can be avoided.

To what degree should I involve my associate in assigning job responsibilities to the office staff?

In any office setting where there is more than one staff person, job responsibilities are not always assigned in the most efficient or logical manner. While one would assume that responsibilities would be assigned to the person most qualified to do the job that is not always the case. Seniority, personal preferences, training, and even a person’s motivation to do difficult work can influence which jobs they are assigned.

It is the doctor’s responsibility to make sure that the office is run in the most productive manner possible. When replacing a chiropractic assistant, it may not be in the best interest of the office to simply assign her responsibilities to whoever is hired. Depending on the size of the practice, it may make more sense to reorganize the work based on the skills and abilities of other staff members. This may allow the “promotion” of another CA or the opportunity to assign more demanding work to those that have more experience.

Conflict among staff members will occur if assumptions are made about the responsibilities of the departing CA, the interests of the remaining CAs, or the skills required for different tasks. To avoid interoffice conflict, the doctors must:

- understand the current function of each staff person
- agree on the quality of work each person is doing
- agree on who is capable of taking on the departing CAs work
- reassign each individual and provide training if necessary
- hire a new CA to take over the functions now assigned to her

This is not particularly difficult because, while each job in a chiropractic office is important, one job is easily distinguishable from another. This evaluation process, however, should not be taken for granted. The doctors in the office and the office manager must sit down and reevaluate each item on the above list whenever it becomes known that an employee will be leaving their job. Each time this evaluation process is completed, the impressions of a staff person’s abilities may change. Impressions from a year ago may no longer be valid, as experience and skills may have been acquired. Differing impressions about a person’s abilities are best resolved by candid discussion between the doctors and/or the office manager. The individual responsible for the administration of the clinic should make the final decision if a consensus can not be reached.

When a practice has a big problem to contend with, such as the illness of a key employee or a computer system that fails, everyone is usually able to pull together and work cooperatively until the crisis has past. Little problems, on the other hand, tend to wear on people so that day-by-day, bit-by-bit, the harmony that is so important in a small business is lost. This often occurs because there is a tendency for some doctors to ignore small problems until there is a mini crisis, and then deal with the mini crisis in a cursory manner without getting to the root cause of the problem.

Are there any circumstances where I am exempt from paying overtime?

Persons whose primary duty consists of administrative, executive, or professional work are exempt from overtime in certain circumstances. They must qualify under the following definitions for each type of work:

“Executive” means an employee employed in a bona fide executive capacity who meets the following criteria:

1. The employee’s primary job responsibility consists of the management of the practice or a department of the practice; and
2. The employee customarily and regularly directs the work of two or more other employees; and
3. The employee has the authority to hire or fire other employees or their suggestions and recommendations about the hiring, firing, advancement or promotion or any other change of status of other employees is given particular weight; and
4. The employee customarily and regularly exercises discretionary powers; and
5. The employee does not devote more than 20% of his or her work hours to activities that are not directly and closely related to the performance of the work described in points 1 through 4. This does not apply to employees that are in sole charge of an independent practice or a physically separated branch practice, and
6. The employee is compensated on a salary basis at a rate of $700 per month or more.

“Administrative” means an employee employed in a bona fide administrative capacity who meets the following criteria:

1. The employee’s primary duty consists of the performance of office or non-manual work directly related to management policies or general business operations of the practice, or
2. The employee customarily and regularly exercise discretion and independent judgment; and
3. The employee regularly and directly assists the doctor or an employee employed in a bona fide executive or administrative capacity; or they perform work requiring special training, experience, or knowledge under general supervision.
4. The employee does not devote more than 20% of his or her hours to activities which are not directly and closely related to the performance of the work described in points 1 through 3; and
5. The employee is compensated on a salary or fee basis at a rate of $700 per month or more.

“Professional” means an employee employed in a bona fide professional capacity who meets the following criteria:

1. The employee’s primary work consists of tasks that require knowledge of an advanced type in a field of science or learning customarily acquired by a prolonged course of specialized intellectual instruction and study, as distinguished from a general academic education or, work that is original and creative in character in a recognized field of artistic endeavor , and the result of which depends primarily on the invention, imagination, or talent of the employee, or
2. The employee’s work requires the consistent exercise of discretion and judgment in its performance; and
3. The employee’s work is predominantly intellectual and varied in character (as opposed to routine work) and for which the product or the result accomplished cannot be standardized in relation to a given period of time; and
4. The employee does not devote more than 20% of his or her hours to activities which are not an essential part of the work described in points (1) through (3); and
5. The employee is compensated on a salary or fee basis at a rate of $750 per month or more.

Can I use a compensatory time (“comp time”) plan to reimburse employees who work overtime hours instead of paying overtime pay to these workers?

Compensatory time may only be used in the same week the work is performed.

Must we give our employees meal or rest breaks during a work shift?

Employees under 18 years of age must receive at least a 30-minute duty free meal period when working a shift greater than 6 hours in duration. State law recommends that employers provide similar breaks to adults but does not require breaks. If you provide breaks of less than 30 consecutive minutes in duration, the break time must be counted as work time.

You must also pay all employees for “on duty” meal periods. An “on duty” meal period is one where the employee is not provided at least 30 consecutive minutes free from work, or where the employee is not free to leave the premises during the meal period.

State law does not require that breaks be provided to employees. However, breaks of less than 30 consecutive minutes are considered work time and must be paid for. You may not deduct from an employee’s wages for any time off of less than 30 consecutive minutes.

How do government agencies determine whether workers are ICs or employees?

There is no single, clear-cut test for classification. Different legal tests for determining worker status are used by various government agencies, including:

• the Internal Revenue Service
• state unemployment compensation depart ment
• state worker’s compensation department
• state tax departments
• the United States Labor Department, and
• the National Labor Relations Board.

Each of these agencies is concerned with worker classification for different reasons and has different biases and practices. Each agency normally makes classification decisions on its own and need not consider what other agencies have done, though they are often strongly influenced by it. As a result, it’s possible for one agency to find that a chiropractor is an IC and another that he or she is an employee. Generally, if the chiropractor passes the IRS “test”, they will be considered an IC by all other state and federal agencies.

What is the “test” the IRS uses to determine if a chiropractor is an independent contractor?

To determine whether an individual is an employee or an independent contractor under the common law, the relationship of the chiropractor and the practice must be examined. In any employee-independent contractor determination, all information that provides evidence of the degree of control and the degree of independence must be considered. Facts that provide evidence of the degree of control and independence fall into three categories: behavioral control, financial control, and the type of relationship between the parties.

Behavioral control Facts that show whether the business has a right to direct and control how the worker does the task for which the worker is hired, including the type and degree of instructions that are given to IC chiropractor. An employee is generally subject to instructions about when, where, and how to work. All of the following are examples of types of instructions about how to do work:

• When and where to do the work
• What chiropractic assistants to hire or to assist with the work
• Where to purchase supplies and services
• What work must be performed by a specified individual

Even if no instructions are given, sufficient behavioral control may exist if the employer has the right to control how the work results are achieved. The key consideration is whether the business has retained the right to control the details of a chiropractor’s performance or instead has given up that right.

Financial control. Facts that show whether the employer has a right to control the business aspects of the chiropractor’s job include:

• The extent to which the worker has unreimbursed business expenses. Independent contractors are more likely to have unreimbursed expenses than are employees. Fixed ongoing costs that are incurred regardless of whether work is currently being performed are especially important.

• The extent of the chiropractor’s investment. An independent contractor often has a significant investment in the facilities he or she uses in performing services for someone else. However, a significant investment is not necessary for independent contractor status.

• The extent to which the chiropractor makes services available to the relevant market. An independent contractor is generally free to seek out business opportunities.

• How the practice pays the chiropractor. An employee is generally guaranteed a regular wage. This usually indicates that a worker is an employee, even when the wage or salary is supplemented by an incentive plan of some type. An independent contractor is normally not guaranteed any amount is completely responsible for earning their compensation by their personal productivity.

• The extent to which the worker can realize a profit or loss. An independent contractor can make a profit or loss.

Type of relationship. Facts that show the parties’ type of relationship include:

• Written contracts describing the relationship the parties intended to create.

• Whether the business provides the chiropractor with employee-type benefits, such as insurance, a pension plan, vacation pay, or sick pay.

• The permanency of the relationship. If you engage a chiropractor with the expectation that the relationship will continue indefinitely, rather than for a specific period, this is generally considered evidence that your intent was to create an employer-employee relationship.

The IRS website has additional forms and publications if you are uncertain as to the proper employment classification for an individual.

What are some things I should think about before I hire an associate?

Hiring an associate is not something that is generally done on the spur of the moment. Some doctors may spend months, or even years, conceptualizing what it would be like to have an additional doctor in the practice. They anticipate:

• how their practice will grow in size with the addition of a new doctor.
• the kind of person they would like to share their practice with.
• the potential for this person to buy the entire practice at some point in the future.
• what they will do with their additional free time.
• how much it will cost for the associate’s salary and benefits.
• how they will handle the associate’s administrative needs.
• what might happen if the associate does not work out.

If practice owners would spend as much time on the process to select the right associates as they do daydreaming about having an associate, they could avoid a multitude of problems. Consider that a practice owner will spend nearly as many waking hours with an associate as they as do with their spouse. And yet, there is considerably more time and effort spent finding a spouse than there is an associate. Obviously, there are many more aspects to a relationship with a spouse than there are to a business associate, but nonetheless, it is amazing how quickly some doctors hire their associates. It is no wonder that so many doctors go through one associate after another. With a more professional approach to each segment of the selection process, both parties will benefit.

What approaches are available that can be used to develop leads for an associate?

Each of these approaches can yield results.

Ads in the Wisconsin Chiropractor. With chiropractic colleges graduating more doctors than ever before, it is definitely a buyer’s market when it comes to selecting a new associate. All an established doctor may need to do is put a single ad in the state chiropractic organization’s newsletter to receive several dozen responses from new graduates. This approach is particularly useful if the doctor is looking for an individual that has some clinical experience.

University/College Recruiting. The most intensive approach to recruiting is to visit chiropractic universities/colleges on a regular basis. Just as major corporations interview potential employees as much as a year ahead of their graduation dates, established doctors also have the opportunity to interview well in advance of graduation dates. The earlier one gets started, the wider the selection of candidates. Every chiropractic college has a job placement office which is delighted to list those practices seeking associate doctors and will set up interviews for interested students.

Campus recruiting. This not only allows for interviewing a wider selection of students, but you can increase the probability of finding a candidate with compatible interests if you invite high potential candidates to shadow you and do some administrative work during break periods. A couple days of this type of exposure will give the doctor an excellent understanding of your practice and work ethic.

State conventions and CE Programs. Should the above approaches not be feasible, potential employees can be met at a state’s conventions and continuing education programs. Some states offer a special area for prospective employers and employees to meet. If this is not available, simply call the individual responsible for registration and ask for a list of students attending upcoming events.

I have a list of individuals looking for a job as my associate. How can I trim the list down so that I do not have to give a full interview to each candidate?

The telephone screening process is the best method to utilize before inviting an individual in for a personal interview. Across the business world, professionals who utilize telephone interviews as a screening device state that it saves them hours and hours of frustration and time they would have spent interviewing poorly qualified candidates. This brief telephone interview insures that the initial goals and desires of the candidate are not out of line with what the practice has to offer. A telephone interview allows the practice owner to:

- candidly describe the type of individual they are seeking
- ask the candidate about their grade point average and employment background
- describe the clinic location, working hours, and days off
- ask the candidate directly about their compensation expectations
- get a feel for the candidate’s personality

This telephone screening process completely favors the practice owner. They have the opportunity to probe into the areas they think are most important and weigh the candidate’s response against their expectations. If a candidate’s response to the practice owner’s questions is unsatisfactory, the conversation can be terminated quickly without having to waste time on a full interview. In the time it would take to personally interview one candidate, 6 to 9 candidates can be screened on the telephone.

The telephone screen does more than supply the answers to a few well chosen questions. It also allows both parties to determine if there is any chemistry between them. Chemistry is very important and yet is often overlooked by doctors who just want an associate ‘who can get the job done’. What they forget is that a multi-doctor practice has to be concerned about more than the relationship between the doctors and the patients. Its doctors must have the chemistry necessary to form a productive team to handle clinical decisions, resolve financial issues, and coordinate staff work.

The most important benefit of the associate/partner relationship is not a financial. It is the potential that their chemistry will allow each of them to more fully develop their clinical and interpersonal skills. If this chemistry exists, one plus one may equal more than two. Without it, one plus one may equal less than two if the lack of chemistry causes personal or office productivity to decline.

What are the key elements to conducting a good associate interview?

Even if a candidate is screened by telephone, personal interviews are absolutely necessary to provide a more in-depth understanding of the individual. Some individuals are not very forthcoming on the phone and may reveal far more of themselves in person. In addition, observing a person as they answer questions gives you an entirely different perspective than that of a phone interview.

When a candidate is invited to a personal interview they should not be told how long the interview will last, and it is best not to invite the candidate to observe patient care before or after the interview. If the interview goes poorly, time does not have to be wasted explaining your clinical approach to patients, giving tours of the facilities, or introducing staff. If the discussion is productive, the interview time may be extended or the candidate may be invited back for a more extended discussion. Here are the key components to the initial interview:

Introduction It is common for both parties to be a little nervous at the beginning of an interview. To help you get comfortable with each other, it is a good idea to keep the first 5 - 10 minutes of conversation light. Your objective is to find a subject or two that will help the candidate relax. If both doctors went to the same school, there are plenty of stories that can be exchanged. If not, talking about a person’s family or how they made the decision to choose chiropractic as a career can be effective ways to ‘break the ice’. The more relaxed the candidate is at the beginning of the interview, the more value both parties will receive throughout the remainder of the interview.

Background Since practice owners do not have the opportunity to hire professionals on a regular basis; it is most productive to ask questions in a logical order to insure that all of the baseline data is obtained before a particular area is explored in-depth. While the objective is to obtain a complete picture of the individual’s background, one must always be careful that the interview does not get into areas which violate the candidate’s right to privacy (such as age, sex, or religion). The easiest way to gather information is to have the candidate tell the story of their professional life beginning back in high school. That story should produce most of the following information:

• How did they perform academically in high school?
• What made them decide to attend chiropractic college?
• If their father or mother influenced their choice, would they have chosen a different career had the decision been completely their own?
• How did they choose their college?
• Was college difficult for them?
• How were their grades in their first trimester? Did they get better over time?
• What subjects did they find most interesting?
• Which subjects did they excel in academically?
• How much time did they spend studying?
• Did they have a job in addition to attending classes?
• How did they pay for their tuition and expenses?
• How did they rank academically in their class?
• How did they do on the national boards? The state boards?
• What adjusting technique do they prefer?

These questions provide both factual information and an insight into the attitudes during their academic life. The answers will provide an idea of their ability to compete intellectually with others in their peer group and how seriously they approached their studies. Naturally, every candidate will tell their story in a different way. Some will focus a disproportionate amount of attention in one area. Having this list of questions can help fill in the blanks for areas that are missed or glossed over. Likewise, each hiring doctor will have their own prejudices about what is important in a candidate’s background. If academic accomplishment is an important factor in selection, the candidate may be asked to supply their college transcripts to verify the courses they took and the grades received. College instructors may also be requested as references so an outside perspective may be obtained as to the candidate’s scholastic aptitude.

The next series of questions relate to the candidate’s goals beyond graduation.

• When did you start looking for a position?
• How would you describe the ideal position?
• Have you had any interviews? How many? With whom?
• Do you plan to stay in this area on a long term basis?
• What are your compensation expectations?

If the candidate is currently working for another doctor as an associate, here is a list of questions to help understand how that work experience has shaped the candidate.

• How were you recruited to join Dr. practice?
• Did you receive any training? If so, what kind?
• What did you find most difficult in the transition from student to doctor?
• How many patients per week do you currently see?
• How are patients assigned?
• Do you have any administrative responsibilities in the practice?
• What aspects of this practice did you like? Dislike?
• Why, specifically, do you want to leave?

If the candidate has already held an associate position with another doctor, particular attention should be paid to the reason given for making the change. There are many good reasons to seek a new job. Relocation due to marriage, a desire to live in a different climate, the opportunity to work in a different size practice are all valid reasons. There is also the possibility that the reason offered for wanting to leave has been made up to cover up poor performance. If an individual is coming from another practice, be sure to review the question dealing with the “reference checks” in this chapter.

When the candidate is finished relating their school and/or employment history and has answered preliminary questions, it is time for them to relax and have the doctor give them some insight about him or herself. The goal is to give them an understanding of how the decision was reached to add an associate to the practice. Generally, telling the story of one’s professional career helps to give perspective and begins to build the foundation of trust that will be absolutely critical to developing a successful team. It is always best to resist the temptation to embellish accomplishments. A potential associate wants to know the doctor’s “real” personality and what they will be like to work with on a daily basis. Just as the practice owner wants accurate information upon which to base their decision, so does the associate.

The attributes you are seeking in an associate are an important part of the story. You should fully describe the type of person being sought, the work ethic expected, the anticipated days and hours expected in the office, and the amount and type of administrative work for which the associate will be responsible. If the possibility exists for ownership of any type in the future, this can also be discussed. Be cautious in discussing the potential for ownership of any kind. It is better to be conservative about the potential for ownership than to create an expectation on the part of the associate that ownership is likely to happen in a year or two.

If the expectation of ownership is created and it fails to materialize in the time frame that was discussed, the relationship with the associate will deteriorate rapidly and, depending on the way the promise was expressed, the practice owner may even face the possibility of litigation. The best interviews are conversational in nature where both the practice owner and the potential associate open up about their strengths, weaknesses, and ambitions for the future.

I was an associate when I came out of school 20 years ago. Why shouldn’t I pay an associate in the same way I was paid?

Forget about what you made 20 years ago. The system that worked then will not work for a student graduating today. Because students routinely graduate with debts approaching $100,000, entry level compensation must rise proportionately to the increased cost of obtaining a chiropractic education.

What are the advantages and disadvantages of paying an associate a straight salary?

Advantages There is no ambiguity on the amount of compensation that will be received by the associate. Associates prefer a straight salary because they can easily set up a budget for school loans, car payments, and living expenses. Because there is less uncertainty, the practice owner is likely to pay less under a straight salary than other forms of compensation if the associate performs up to expectations.

Disadvantage. A straight salary tends to overpay underachievers and underpay overachievers. A person on salary may not be motivated to build a practice as quickly as someone who has an incentive built into their compensation.

If the associate excels, they may feel they have been taken advantage of if their salary is not proportionate to their revenue contribution. An associate who feels they have been mistreated is not likely to stay with a practice.

Computation Method. The salary is typically set by estimating the number of patients that will be seen by the doctor and the revenue that will result from this care. From the gross revenue amount, the practice owner will subtract the amount necessary to cover practice overhead, benefits paid for by the practice, and amount to recover their investment in the practice. The remaining balance is fine tuned to match the expectations of the associate or local market conditions. As the associate gains experience and/or builds a referral base, the salary would typically be increased to reflect this additional contribution to the profitability of the practice.

What are the advantages and disadvantages of paying an associate based on 100% production based compensation?

Advantages. At the opposite end of the spectrum from a straight salary is compensation based on a percentage of the revenue that an associate generates for the practice. A practice owner who pays on this basis has virtually no risk. The associate is completely responsible for developing a practice; if they fail, the practice owner has not lost any money. If an associate has an established referral base or is extremely confident in their ability to generate referrals, they have the potential to earn more money from this method of compensation than that of a straight salary.

Disadvantages. If an associate had an established referral base or could easily generate referrals, it is likely they would go into practice for themselves instead of serving as an associate. Most associates coming out of school have no money; in fact, most have an enormous debt on which payments must begin shortly after graduation. While they may have considerable confidence in themselves, building a practice takes time and most will not be able to meet their financial obligations under this type of compensation plan. Doctors who accept these types of proposals must be carefully supervised so that patients or insurance companies are not billed for excessive services. Associate turnover can be high because if the doctor does have immediate success in attracting patients or receives a better offer from another practice, they are likely to leave the practice abruptly.

Computation Method. The practice owner begins by determining the relationship of practice overhead to practice revenue. If, for example, a practice generates $260,000 in practice revenue and the costs of operating the practice (excluding owner compensation) are $117,000, the overhead percentage is calculated by dividing the cost by revenue as shown below: $117,000 Practice Costs = 45% Overhead Ratio $260,000 Practice Revenue The costs of operating the practice should include any additional new costs (e.g. additional staff hours or employment benefits) related to the new associate. Because the overhead ratio in the above example is 45%, it does not mean an associate would be paid 55% of all of revenue generated. An additional percentage may be allocated to recover the practice owner’s risk of establishing and operating the practice. Finally, an additional percentage may be allocated to recover the cost of developing the current patient base. The final percentage paid to the associate can be determined after calculating the sum as follows:

_________ Percentage Allocation for overhead + __________Percentage Allocation for practice risk + Percentage Allocation for pt. development. =__________Total Percentage Allocation for Cost 100% - % Total Percentage Allocation for Cost = % Percentage of Revenue Paid to Associate

What are the advantages and disadvantages of paying an associate based on a salary draw against production?

Advantages. This method of compensation can be very effective when an associate is assigned patients in order to reduce the workload of the practice owner. It is somewhat like a blend of salary and performance based compensation. As long as the associate continuously improves their productivity, it allows the practice owner to gradually recapture salary paid earlier in the associate’s employment when he or she was not as productive. The risk to the practice owner is somewhere between paying a straight salary and compensation based on performance.

Disadvantages. This approach does not work well if the associate is not assigned a portion of the practice owner’s patient base and is expected to generate all of their revenue from their own patient base. If the associate must develop all of their own patients, they may never generate enough revenue to “earn back” the salary that has been advanced to them. The further behind the associate gets, the less motivation they may show. This may accelerate the associate’s desire to look for another position.

In the early months of employment, the associate will almost never earn back the draw. But in a well constructed financial relationship, the production of the associate will continue to grow until the “draw” is actually less than what the associate has earned. At this point, the compensation agreement may require the associate to make up any deficit in the salary account before the draw is raised. Or, the owner may raise the draw with the expectation that the associate will continue to increase his or her production. At some point, when the associate’s production remains at a consistently productive level, it may be in the best interests of both parties to discontinue the draw and switch to a permanent compensation based on a percentage of collected revenue.

What are the advantages and disadvantages of paying an associate based on salary with an additional payment based on production?

Advantages. The salary guarantees the associate a base level of compensation with the incentive to earn “bonuses” as certain revenue goals are achieved. The target levels for “bonuses” can be set in any way that suits the objectives of both parties. This method works especially well when the practice owner envisions a long term relationship or when the associate is being groomed to take over the practice.

Disadvantages. If the salary is set too high, the associate may not be motivated to develop additional referrals. In a situation where the associate is being groomed to take over the practice, the associate may not understand the amount of work necessary to sustain the patient base. Unless the practice owner insists on the associate spending a portion of their time in practice development, this arrangement could lead to a practice with the same revenue base but much higher overhead.

Computation Method. The base salary is calculated based on a percentage of the minimum revenue expected to be produced by the associate on a consistent basis. Because this method of compensation is most often used by doctors who wish to transfer a portion of their patient load to an associate, the expected revenue is relatively easy to calculate. A production bonus is then paid on the collected revenue generated above this base amount. The bonus usually represents revenue earned from referral patients generated by the associate.

The owner partner has the option of whether to pay production bonuses as they are earned or to require that salary deficits be eliminated before production bonuses are paid.

What are the advantages and disadvantages of paying an associate based on salary or draw with paid benefits based on production?

Advantages. In addition to compensation there are a range of benefits which are attractive to a young doctor. These include health, disability and life insurance, retirement programs, state association dues, and continuing education. Some practices will pay all or a portion of these benefits as part of a financial package to entice a doctor to work for them. Others will offer to subsidize these costs on a sliding scale based on the performance of the doctor. Associates will be interested in any benefit that they would have to pay for if it was not provided to them. There is also a potential tax advantage for them if benefits are provided by the employer.

Disadvantages. Depending on the family status of the associate, the cost of providing a full set of benefits can add thousands of dollars in overhead to a practice. Once provided, it is very difficult to withdraw a benefit. Some practices provide a full set of benefits without considering the needs of the individual. For example, life insurance may not be necessary for a single doctor without dependents. Even health insurance may not be necessary if a spouse has that benefit available at their place of employment. Larger practices are usually able to purchase benefits at a lower cost than small practices which can put the smaller practice at a disadvantage when they compete for a new associate.

Computation Method. If benefits are provided as part of the package to induce the associate to join the practice, an offsetting reduction is generally made in the amount of salary offered to the individual. If benefits are provided to an associate whose compensation is based on production, the percentage payout is generally lower to account for the cost of the benefits.

What are the advantages and disadvantages of paying an associate on a production based compensation with a payment for overhead?

Advantages. This approach allows the practice owner to make it appear as if the associate is making more by paying the associate at a higher percentage of collected revenue and then deducting overhead costs instead of paying a smaller percentage of collected revenue and including overhead costs in the discount. This method is favored when a smaller practice is merging with a larger practice, especially if the larger practice has additional space which can handle the needs of another doctor. Some associates may favor this approach because they pay for overhead in direct proportion to their revenue.

Disadvantages. Since overhead costs are generally fixed, basing overhead on a percentage of collected revenue will have the effect of either overpaying or underpaying for overhead. This favors the associate when their production levels are low and favors the practice owner in later years as production levels are consistently higher. If the charge for overhead is assessed on a percentage basis, it can be difficult to calculate because the cost of most overhead is fixed and does not vary with the amount of revenue generated by a practice. For example, rent (or mortgage payments), heat, electricity, and maintenance will have to be paid regardless of the number of patients treated. Even staff salaries are relatively fixed in that the number of staff people does not usually change until the volume of patients greatly increases or decreases.

Computation Method. Generally an associate is paid 100% of their gross collected revenue less the overhead percentage, assuming they are generating all of their own patients. If the practice owner is the primary source for the associate’s patients, the associate may be paid at a figure less than 100% of collected revenue to account for the investment cost of developing the practice and the patient base. The overhead percentage can be fixed or recalculated on an annual basis.

An alternative is to allocate each item of overhead to the doctor responsible for its cost. For example:

• Rent or mortgage payments would be allocated on the basis of square footage occupied by each doctor. Common areas would be shared equally.
• Utilities would be proportionally al located based on the number of hours each doctor worked.
• Staff salaries and benefits would be proportionately allocated based on the gross revenue volume of each doctor.

If this method is selected, it is best to agree that recalculations will only be done on an annual basis because of the time consuming process of allocating cost.

What are the best references to check from the list that is offered?

Each potential associate candidate will offer a list of references. These are an acceptable starting point but are likely to consist of people who cannot wait to give a glowing testimonial about the candidate’s character and/or work habits. The people who are most important to contact are those who have interacted with the candidate on a professional level in the last few years. Here are some examples:

Present employer. Candidates who are currently working for another doctor may not want their current employer to be contacted. They may justifiably fear they could be fired if their employer finds out they are looking for another job. For this reason, no reference checks should ever be conducted until a decision has been made to hire the individual. An offer can be made subject to a satisfactory check of their references. The candidate should always be told before references are checked, so they may explain their job search to their current employer, if necessary, before the reference call arrives.

If there is a problem with the examination, diagnostic, treatment, or administrative skills of the candidate, no one will be more aware of the problem than the current employer. While it may be difficult to call another doctor about hiring their associate, it is better to endure this brief agony than hire a poorly skilled doctor. Here is one approach for the opening of a reference call:

Good morning, Dr. Allen, thank you for taking my call. My name is Dr. Jim Hill. I am a chiropractor practicing in Centerville about 100 miles south of you. I have been looking for an associate and have been talking to Dr. Paul Burke who works for you. Paul told me that he has spoken to you about his plans to relocate (pause for confirmation).

If you don’t mind, I have just a few questions that will help me make sure that I am making the best choice for both Paul and myself. How long has Dr. Burke worked for you?

How would assess the quality of his work? You may get a general, or a very specific answer. If the answer is general, you want to go back and ask specifically about each of the following areas:

1) Examination skills
2) Diagnostic ability
3) Do patients generally complete his treatment plans?
4) Documentation skills
5) Does he have trouble get ting reimbursement from insurance compa nies?
6) How do patients like his “bedside manner”?

To avoid general responses, it is best to ask specific questions such as “Are there any particular areas where his skills are weak or still developing?”

Does Dr. Burke have responsibility for any of the practice’s administrative work? If so, what kind of responsibility does he have?

How does Dr. Burke get along with your CA’s? Does he have any supervisory responsibility for their work?

Has he been able to develop referrals on his own? Does he spend any time on community activities that have led to referrals?

Is there anything about his background that I should be cautious about?

Paul said that he is compensated in the following way. Is this accurate?

This may seem like a lot of questions, however, you probably will not have to ask more than half of them. Once the conversation gets going, the current employer is likely to give you most of the information you need as he or she tells you the story of their relationship. Courtesy is very important. Be mindful that the present employer is not likely to be happy that this individual has decided to relocate. If they express bitterness or frustration, it is better to empathize with them; after all, you want as unbiased an impression as possible of this person’s abilities. Be sure to express your gratitude for the time spent with you at both the beginning and at the end of the conversation.

Preceptor doctor. Doing a reference check with the doctor who served as a preceptor is difficult because the questions need to be focused on the end of the preceptorship after the doctor had the opportunity to improve his or her skills rather than the early days when the skills were still undeveloped.

Each of the following areas should be addressed specifically. As a reminder to get both positive and negative comments, a table like the one below could be used during the interview.

Examination skills
Diagnostic ability
Adjusting skills
Documentation skills
Communications ability
Ability to work with staff
Administrative skills

Everyone hopes that the associate they hire right out of school will be fully competent to handle the day to day challenges of a real practice. Unfortunately, everyone needs some on-the-job training and most need extensive training.

By understanding the strengths and weaknesses of a candidate before they are hired, a decision can be made as to whether it is worth the investment of time to “fill in the gaps” of the doctor’s training. If the individual is worth the investment, schedules can be arranged so that the practice owner can work alongside the associate to assist in honing their skills.

Clinical instructors. If the individual you wish to hire did not have access to a preceptorship program, the best source to assess their competence will be the student’s college instructors. The most important of these are the clinic and technique instructors. While letters of recommendation from instructors are useful starting points, they rarely provide the type of detail necessary to help make a hiring decision. The following list can be used as a guide when verifying the aptitude of a candidate. Remember to be appreciative when an instructor shares their observations.

Other employers. Working at a pizza parlor or a video store may not seem like very good preparation for a career as a chiropractor, but the way an individual approached these jobs can tell a lot about how they will approach their responsibilities in a practice. The following questions will give some insight into the applicant’s work ethic and their sense of responsibility.

• How many hours did the individual work?
• Did they have any supervisory responsibility?
• How did you rate their performance?
• Did they just “do their job” or were they always willing to “give a little extra”?
• Were they always punctual?
• Did they use a lot of sick days?
• Did they ask for additional days off around exam times?
• Did they give you proper notice when they quit their job?
• Was there any part of their performance or their personality which you feel could use improvement?

Grade transcripts. Grades are not always the best indication of a person’s ability, especially if an individual balanced work or family responsibilities along with their academic responsibilities. Grades should play a role in the hiring decision because they measure how well a person has mastered the information necessary for them to perform their chiropractic duties.

During an initial interview, it is natural for the subject of grades to come up. New graduates have a tendency to disguise their actual performance by using general statements such as “I did really well”, or I had a B+ average in the subjects that I enjoyed (while conveniently forgetting the bad grades in everything else). It is easy to avoid splitting hairs over this topic. When the candidate’s references are requested, they should also be asked to supply a copy of their academic transcripts (both from their chiropractic university/college and their pre-chiropractic course work). Once the data has been obtained, its meaningfulness can be assessed. If a hiring decision is made without this data, the decision to hire this person may have been based on the applicant’s imagination rather than reality.

Reference checking is hard work. It involves making phone calls to strangers and asking them to share details about a person’s life that may not be positive. Because it is difficult, many people are tempted to go with their instincts and eliminate the reference checks. Before one is tempted to follow this path, they should make a few phone calls to colleagues in the area who have hired more than one associate. Ask them about their worst experience. Chances are that experience could have been avoided if they had done their homework before they made the job offer.

What is the proper way of extending a job offer so that there are no misunderstandings of the offer in the future?

Before an offer of employment is made, both parties should have a pretty good idea of the terms that will be included. Regardless of the verbal understandings that may have been reached, nothing should ever be taken for granted. The most professional approach is to make the offer verbally and then to follow up with a written confirmation. The written confirmation can be as simple as restating the intention to hire the person and confirming the starting compensation as shown in the following letter.

Date

Paul Burke, D.C.
456 Haywood Avenue
Centerville, WI 54867

Dear Paul:

Thank you very much for all of the time you have spent with me over the past couple of weeks. You have done an excellent job preparing yourself for your chiropractic career. I am very pleased to offer you a position as an Associate at the Centerville Chiropractic Clinic. Your initial compensation will consist of a starting salary of $38,500 per year. You will earn additional incentive compensation at the rate of 30% of your collected revenue over $ . We will review both your base salary and your incentive compensation at the end of each six month period.

In addition to our salary and incentive plan, we also offer the following benefits:

- Health Insurance
- Disability Insurance
- Malpractice Insurance
- WCA dues

For the last 17 years, Centerville Chiropractic has established a reputation of providing excellent chiropractic care. As our community continues to grow, we need someone with your skills to help us maintain our reputation for excellence. I hope that you will accept our offer and become part of our team.

I look forward to hearing from you.

Sincerely,

What are the main points that should be covered in a “non-compete” clause?

It is especially important that the following areas be considered:

• The “non-compete” clause should generally be part of a larger contract. If it is added as an addendum to a preexisting contract, it is very important that it contains a clear listing of the compensation that is being paid in exchange for the “non-compete” clause. If an “agreement not to compete” is signed as a separate document after employment has begun, some courts require there to be an increase in salary, benefits, or an extension in the length of the contract itself in order for this agreement to be enforceable.

• Restricting an employee’s right to compete is generally considered reasonable only if the restrictions are not greater than what is necessary to protect the legitimate interests of the employer, they are not unduly harsh and oppressive to the employee, and they are not injurious to the public.

• The agreement can not impose unreasonable restrictions on the employee’s future ability to earn a living. This issue involves analysis of the following three factors:

1) The time period during which the restrictions are imposed.

To be considered reasonable, the time period must not be longer than is absolutely necessary to protect the legitimate interests of the employer. The test for chiropractors in this area might involve looking at the frequency with which a patient returns to a chiropractor. Because active patients generally visit their chiropractor at least once a year, a restriction of 12 to 18 months might be considered reasonable, whereas a restriction for 5 years would clearly be unreasonable.

2) The geographic area in which the employee is barred from competing.

The test for this factor is the area from which the chiropractic practice draws its patients. An agreement that would try to ban an associate from practicing anywhere in the state would not be reasonable. One which had a specific mileage radius from the clinic (which was similar to the radius from which the practice derived its patients) would have a much better chance of being enforced.

3) The activity which the covenant seeks to ban.

The practice owner only has the right to limit potential competition from the associates’ activities as a chiropractor. If the associate wishes to engage in a different type of activity within the chiropractic profession, or in a new profession altogether, the practice owner would have no right to stand in their way.

 

I am going to hire my first associate. How important is it that my offer details every element of his/her compensation?

Your agreement regarding compensation may be simple or complex. To the degree possible your agreement should be as specific as possible, and in writing, to avoid the possibility of a misunderstanding. If any of the following are offered to the employee, they should be listed in the written agreement:

- Salary
- Bonus, incentive, or production based compensation
- Employer provided life, health, disability, or malprac tice insurance
- Pension plans
- Vacation benefits
- Employer reimbursed state or national chiropractic or ganization dues
- Employer reimbursed continuing education expenses
- Employer provided housing or automobile
- Severance benefits

The employment agreement should specify whether you pay for the entire benefit or just a portion of the cost. It is particularly important to address the following issues when discussing vacation:

- whether the associate may carry unused vacation time from one year to the next
- whether unused vacation time is forfeited at the end of each year
- whether the associate, at his option, may choose to forgo some or all of his vacation days and simply take vacation pay at the end of the calendar year or at the end of the employment relationship
- whether the employee may take unpaid vacation days and, if so, how many each year

I am re-negotiating my associate’s contract. I have had difficulty in making sure he is here when patients call for care. How important is it that I specify his hours or duties as part of the agreement?

Chiropractic practices must often change the hours of their operation to meet the changing demands of managed care companies. A new associate may not be aware that evening and weekend hours are necessary to meet the scheduling needs of patients. In addition, the practice may decide that it is important for the associate to spend a certain amount of time being involved in community projects or in the direct or indirect marketing of the practice. If these areas are important to you, they should be specified in the employment agreement.

The following is an example of the type of language used in employment agreements which contain hour or duty clauses:

Duties: The Associate agrees to perform professional chiropractic services as a full time chiropractor in accordance with the provisions of this agreement. In addition, the Associate may be assigned administrative duties related to the operation of the Employer’s chiropractic practice. The Employer may, from time to time, extend or curtail the Associate’s precise services. The Associate shall perform his/her duties in accordance with all applicable statutes, regulations, and rules. The Associate further agrees to abide by all administrative and personnel policies applicable to all employees of this organization. The Associate shall not engage in any other professional health care services, other than the activities set forth in this agreement, without the Employer’s prior written consent.

What is the best section in the newspaper to place a “help wanted” ad for a CA?

You have four choices for your ad:

Health care
Professional
Administrative
Clerical

In big cities where there are likely to be a large number of individuals trained in specialty “chiropractic technician” programs, the Health Care classification may give you the best results, especially if you are seeking an individual whose job responsibilities will focus on clinical tasks. The professional classification is most useful when the individual’s responsibilities will focus on office management. When billing and accounts receivable are the focus of the CA’s job, the administrative classification will probably produce the largest response. For CA positions that emphasize reception, appointment setting and patient interaction, the clerical classification is the best place for your ad.

Under what circumstances may I delegate work to a CA?

Your authority to practice comes from the state of Wisconsin via your chiropractic license. This license is given to you as an individual. It does not give you the authority to allow anyone to do clinical work on your behalf unless it is specifically allowed by the state and the individual has the training required by the state.

A CA may never adjust a patient, make a diagnosis, or do any portion of an orthopedic, neurological or chiropractic exam. Regardless of the individual’s training or experience in other health care fields, you do not have the authority to delegate this type of work. Violations of this rule are very serious. Not only do you face possible disciplinary action by the state, but you also leave yourself exposed to tremendous malpractice risk. If you are ever sued for malpractice, an attorney will review all aspects of your care including the person responsible for providing each service received by the patient. Just imagine your chances in front of a jury if the patient’s attorney can show that a person provided care that did not have the proper education and training (even if it is unrelated to the care that caused the injury).

In additional to educational requirements do I have other responsibilities before work can be delegated to a CA?

You may delegate the performance of some services to a CA or an unlicensed person (an unlicensed person is anyone not licensed as a chiropractor) only if all of the following conditions are met:

• You maintain records verifying that your staff member has successfully completed a didactic and clinical training program for this service approved by the board.

• The individual must demonstrate proficiency in the delivery of that service to minimally competent chiropractic practice standards as measured by objective knowledge and skills testing.

You must exercise direct supervision of the unlicensed person performing the delegated service. Direct supervision means that you must always be on the premises when the service is being provided. Your staff may not perform delegated services if you are off for the day, at lunch, or out of the office running an errand.

• You retain ultimate responsibility for the manner and quality of any service that you have delegated to an unlicensed person.

Please remember, a chiropractor is not allowed to delegate services to an unlicensed individual until after a person has completed their training and passed the exam. This is true even if the chiropractor is short of staff and just needs an individual to “fill in” for a short period of time. To avoid this problem, it is best to cross train as many of your employees as possible.

Our doctors do not work a conventional week. How do we define a “week” for overtime purposes?

A “week” means a calendar week or regular reoccurring periods of 7 consecutive 24-hour periods.

Are there any restrictions on the number of hours that you can schedule an adult to work?

Adults may work an unlimited number of hours per day or per week. You have the right to set the schedule of hours to be worked and the employee does not have the right to refuse to work.

How often must we pay our employees?

You must pay your employees at least once a month. As of each payroll date, you may not owe your employees for more than 31 days of pay.

We have an employee who moved and did not tell us her new address. Then she left a voice message quitting her job. How are we supposed to pay her within the 31 day rule?

If you do not know the address of an employee, you must pay them within 6 days of their request.

 

Are we allowed to require our employees to wear uniforms?

Yes, but you must tell a potential employee about your policies during the interview or at the same time you offer them a job.

We had a major theft of cash in our practice. Can we require our employees to take a lie detector test?

In general, you may not directly or indirectly require that an employee take a lie detector test. However, there some exceptions to the law; one of those exceptions happens to be investigations involving theft, embezzlement, misappropriation or unlawful espionage.

You may only require a lie detector test if the employee had access to the property that was stolen, you have a reasonable suspicion that the employee was involved in the incident, and you, or someone representing you for at least 3 years, sign a statement that is g