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Put Patients or Employees First? The Dichotomy that Isn’t


How exactly does an FQHC best achieve its mission?  My answer has always been that an FQHC needs to stop thinking in “non-profit” terms and all its attendant baggage, and rather focus on running like a business.  Unfortunately, not all businesses are run well, and many are not adapting to the business models that will be effective in the 21st century.

From my perspective, it starts with an understanding that it isn’t “margin vs. mission” and it isn’t “put the patients first and the employees second” (or the reverse).  So many business books want to give you a simple answer, like — “get the right people on the bus and the business will succeed” — except how do we know who the “right people” are, and where do we get the bus?  The truth is, most of these one-line answers are just one piece of a much large puzzle that requires a lot more thought.

Let’s look today at the idea of “putting patients first” vs. “putting employees first.”  The honest truth is that it isn’t a dichotomy — it isn’t one or the other, and it isn’t both at the same time, because they are two completely different things.  A better way to address this is to put it in context, and to put it in the right order:

Design an organization that focuses on providing the highest possible level of care and support for patients, create the right jobs to carry out the mission, then select the right employees for the mission and treat them the right way.

When you design an organization the right way, you need to consider only what you are trying to accomplish.  What hours do you need to be open, what services are you  going to provide, where will you be located, all of the things that relate to your purpose, your mission.  These things have nothing to do with employees, and the mistake that many organizations make (and that includes a lot of private sector businesses) is to worry first about the employees they currently have — because they didn’t design the organization first, they just let it evolve.

Once you have a good handle on the mission and how it will be carried out, it is time to look at what kinds of jobs will be needed to carry it out.  The focus is on creating jobs that are both effective in carrying out the mission, and as attractive as they can be to current and potential employees.  Write comprehensive and consistent job descriptions that reflect the true nature of the job.  What are the characteristics of these jobs?

  • They are coherent and consistent.  They make sense… they have a purpose… they contain related and relevant responsibilities and duties.  Don’t put people in a situation where they have to choose which of a set of diverse duties and responsibilities they need to focus on, at the expense of the other half of their job.
  • The duties and responsibilities are primarily carried out at the highest level of the qualifications required for the job.  You may recognize this as one of the basic concepts inherent in the “patient-centered medical home.”  The best employees are going to be the ones most interested in their job, and the last thing you want to do is to have an intelligent and creative CFO doing data entry on routine accounts payable, or an RN doing nothing but rooming patients.
  • They have reporting relationships that make sense, and supervisory/management responsibilities that make sense.  Jobs should report to jobs in a way that issues can be effectively dealt with, and management should be of jobs that are related to the functional area managed.  Don’t make your billing manager also responsible for outreach employees, or your clinic manager responsible for IT people.
  • Whenever possible, they are designed as full-time jobs.  Why?  There is no better recipe for disaster than a lot of part-time employees.  Part-timers are harder to manage, harder to schedule, more likely to turn-over, and place a burden on the full-timers around them.  Full-time jobs are also more attractive to those who can dedicate themselves to the mission, and also provide more income to those who will value the job and not be out the door for a $0.10/hour raise.

When the jobs are properly defined — then and only then should we hire employees, and we should only hire employees who match the design of the job.

  • Hire people who possess the basic qualifications needed for the job.  If you need a professional accountant, don’t hire someone without a degree with the understanding that they will go to school at night to get their degree.
  • Always hire people who are as close as possible to be doing the job the way it is supposed to be done — saving money on someone you will have to train will end up costing you more, and there is no guarantee they will ever reach expectations.  All the time an employee is not doing the job as its defined, things aren’t being done, or someone else is doing them.
  • Be very careful about the intangibles.  Look for “professionalism” in every employee you hire.  I recently attended a seminar where the speaker said “remember, every employee is a marketer, and everything they do is marketing.”  In a health center, every interaction is important, and you can’t afford weak links.

Now we come to what I think is the easiest part, but which seems to be so difficult for many people to understand — pay your employees the right way!  What is the right way? You will be paying your employees the right way if:

  • The pay opportunities for jobs of similar value to the organization are the same.
  • The pay opportunities are competitive in the realistic labor market for each job.
  • Employees are paid solely based on their proven ability to perform the job.

The concepts have been discussed on this blog in detail before, and anyone who says they can’t be implemented in a small organization is trying to sell you the Brooklyn Bridge. Effective compensation programs are not expensive to design or difficult to administer, and in any organization that spends two-thirds of its money on employees, is not a luxury but a necessity.

What we know, after working with health centers for more than 20 years, is that most health centers can afford to pay their employees the right amount, or at least quickly move toward it.  What keeps them from doing it is:

  • Poorly designed jobs, or jobs designed around people.
  • Compensation decisions made in a reactive way, as a hodgepodge of individual decisions based on employee needs or complaints.
  • Continuing to give increases to employees who are paid far beyond their ability to contribute to the success of the organization.
  • Seniority systems that don’t account for performance, and merit systems that can’t possibly bring employees to the right amount of pay at the right time.

So what if you’re not a new organization, but one that has a thirty year history and a lot of baggage?  Well, to put it simply, its not in any way different to design, but can be tricky to implement.  As I’ve told many clients, design the organization the right way, and if you have to keep it in a locked drawer until you can deal with parts of it, that’s fine — just don’t replicate the mistakes when you have a chance to make change.  When employees leave, hire replacements better suited to the jobs you really need.  If jobs need to be expanded, provide training.  Don’t hold on to people who drag you down.

The concepts described above aren’t abstract, and they aren’t revolutionary.  In fact, you might just say they are common sense.  Many organizations don’t use common sense, but the ones that do are the ones that achieve their mission.