Managing your clinical team at a group practice

A psychologist who is constantly late to patient appointments or won’t return patients’ phone calls can quickly earn a group psychology practice a bad public image. Team morale among staff can take a hit if a clinician asks administrative staff to run personal errands for them or simply stops showing up. And problems like failing to file paperwork on time can lead to financial or regulatory problems.

“One person’s actions can potentially bring down the whole practice,” said Larry Beer, EdD, founder and director of Child and Family Psychological Services, a group practice with about 40 clinicians in Kalamazoo, Wisconsin. If the bad behavior by clinicians is serious enough, it can even render the practice vulnerable to legal liability.

Responding to major problems, such as ethical violations or illegal acts, is easy: fire the person. “If someone is dating a client, ‘You’re gone,’” said Beer. “If someone is going into sessions drunk or stoned, ‘Sorry, we don’t do that.’”

But even less egregious problems, such as unreliability or rudeness, can still have a long-term impact on your practice’s reputation, its financial well-being, and patient care if they aren’t addressed swiftly, Beer said. He and other group practice leaders offer guidance on how to prevent and address problems among your clinical team:

When Jason Luoma, PhD, chief executive officer of Portland Psychotherapy in Portland, Oregon, is hiring, he screens out “people who give themselves away” by failing to follow instructions or making minor errors like typos on their applications. He also spends time in interviews clarifying what both the practice and the candidate need and want. “Make sure expectations and goals for both the potential employee and the employer are well articulated so you can tell if the job matches what the person wants and where they want to go,” said Luoma, who currently leads about a dozen therapists plus administrative staff. The goal is to prevent unpleasant surprises while also leaving employees better off in terms of their future career advancement, whether they stay on in the practice or eventually transition somewhere else.

Be sure to ask for letters of recommendation and follow up with a candidate’s references. In addition to asking about a candidate’s competence, find out how well they get along with others, how they respond to feedback, and how they manage problems, suggested Robin Lett, PhD, and Robyn Kittrell, PhD, cofounders of the 17-provider practice Still Waters Professional Counseling in Muncie, Indiana.

Also ask your staff if they know the candidate. “Often they’ve worked with them in other instances and know if they’re a pleasure to work with or a source of negativity,” Beer said. “I want to hear things like that from people I already trust.”

At Portland Psychotherapy, the onboarding process for new hires lays out what’s expected of practitioners. A new clinician first meets with the clinic’s director of clinical operations to learn how to use the medical record system, how to handle billing, and other clinical matters. Then they meet with the office manager to learn all the administrative tasks they’ll be expected to handle plus expectations for handling tasks like submitting paperwork. “They have a series of meetings they go through where they’re trained in all the different procedures that are part of making the business work,” Luoma said. “The more you set clear expectations, the more you don’t have problems down the road.”

And put those expectations in writing, said Robin McLeod, PhD, president and chief business development officer of Natalis Counseling and Psychology Solutions, which has 106 employees, including 86 providers (of whom 17 are trainees completing requirements for licensure at the master’s and doctoral level) in four clinics and several satellite locations around the Twin Cities of Minnesota. At Natalis, new practitioners must sign a form saying they have read and understood the 120-page employee policies and procedures manual, which covers most issues practitioners there might face, including how much continuing education they need to pursue, how they should handle a case consultation, and how to properly encrypt personal devices.

To ensure clinicians are staying on track administratively, Luoma’s practice monitors their paperwork through quarterly peer reviews. The director of clinical operations and administrative staff select a random subset of clinical documents to assess whether the paperwork meets the practice’s standards. “It’s a collegial process,” said Luoma, explaining that the auditors examine clinicians’ “day sheets” summarizing the services they’ve provided to patients to make sure what’s reported matches what’s being billed for. The auditors also review a random subset of clinicians’ notes to make sure they conform to the policies outlined in the practice’s clinical procedures handbook. If practitioners aren’t meeting expectations, the director of clinical operations comes up with a plan for how to improve their work.

“My whole MO is prevention,” said Mary Alvord, PhD, who directs the 19-practitioner practice Alvord Baker & Associates, LLC, with offices in Chevy Chase and Rockville, Maryland. For Alvord, that means training, supervision, and peer consultation throughout the year. In addition to training new hires on legal standards and regulations such as the Health Insurance Portability and Accountability Act (HIPAA), the practice holds regular workshops on ethics, cultural competency, to help clinicians stay on track. New hires also sign a contract agreeing to undergo an hour of supervision with Alvord each week for the first two years at the practice. Some get even more supervision, either because they want or need it. In one case, for example, a practitioner had five additional sessions on using cognitive-behavioral therapy for depression. “Even though it’s time-consuming, it’s probably less time-consuming than handling a problem,” Alvord said.

Alvord’s clinicians can also join peer consultation groups comprised of three to six clinicians for advice and support or simply seek out colleagues for advice on sticky situations—a strategy that has helped keep problematic behavior at a minimum. In other practices, leaders assign mentors to new hires who can act as go-to resources for questions or advice. Some larger practices even try to hire several new clinicians at the same time to create cohorts that can provide mutual support.

At the Behavior Therapy Center of Greater Washington in Silver Spring, Maryland, the practice’s 18 practitioners can draw on the expertise of their colleagues to make decisions about how to handle situations such as invitations to patients’ bar mitzvahs or family funerals. One of the practice’s assistant directors serves as an ethics officer who pulls together ad hoc ethics subcommittees of volunteers whenever an ethical conundrum arises.

“No one has to make a tightrope decision,” said Charles Mansueto, PhD, the practice’s founder and director. “People feel supported and heard.”

When a concern or complaint arises, whether from a patient, a clinician, or a member of the administrative staff, first ask each person involved what happened. If the complaint is warranted, figure out the best way to address the problem. At Natalis, leaders meet with the clinician, then follow up the meeting with a written summary of what was discussed that the practitioner can review and revise.

The practice may also consult a lawyer if the concern could lead to legal problems. That’s smart risk-management, says Lindsay Childress-Beatty, JD, PhD, APA’s interim ethics director. “Allegations of certain behavior, such as illegal behavior or negligence that led to patient harm, should prompt a discussion with counsel,” she said, adding that allegations that the practice failed to take action after being informed of similar past behavior could lead to extra risk. “The practice should also consider speaking to counsel when certain patient variables are present, such as a history of difficulties with multiple therapists or other professionals, currently being involved in custody or other legal disputes, or directly threatening to sue.” It is also wise to consult counsel before terminating an employee, Childress-Beatty added.

Then the remediation process begins. That might mean regular meetings with a supervisor charged with keeping a close eye on the practitioner’s work, for example. In some practices, a formal probation period kicks in after a complaint during which a practitioner is on notice that they must do better. Lett and Kittrell, for instance, give practitioners 30 to 60 days to align their behavior with the expectations outlined in a post-complaint meeting.

If a problem arises, sit down and talk with the clinician to determine whether their behavior is an isolated incident or a pattern, Beer suggested. “Therapists go through our own hard times,” he said, and sometimes—especially during a pandemic—those personal problems can spill over into work, he said. If someone’s behavior has changed recently, listen and try to understand what’s going on. Find ways to support the person, whether it’s meeting with the person more frequently, suggesting a class on boundary issues, or encouraging the practitioner to get counseling of their own.

If their work or problem behavior doesn’t improve, he said, it may be time for the person to move on. “You may have to tell them it’s not a good fit and suggest they go to a clinic where it doesn’t matter if they’re late and can do things their own way,” Beer said.

If a practitioner has committed an ethical violation or a crime, such as sex with a patient or insurance fraud, they have to go, he added. The same goes if they are consistently prompting complaints that are harming the practice’s reputation and doing nothing to improve their behavior. “You have to tell the person we can’t afford to do this together because they’re putting into jeopardy the reputation of the whole place,” said Beer.