Overview

In this chapter, we will highlight some of the key aspects of successfully recruiting a health care professional to your community. Recruitment is a process that consists of several interrelated steps aimed at attracting qualified primary care professionals to practice in your community. There are a number of publications on recruitment and retention of health care professionals that are referenced at the end of this chapter.

This chapter is organized to highlight some of the key steps and activities to be carried out during recruitment. The processes and activities in this chapter are provided for recruitment of all primary health care professionals including, Physician Assistants, Nurse Practitioners, Certified Nurse-Midwives, Dentists, Dental Hygienists, Psychiatrists, Health Service Psychologists, Licensed Clinical Social Workers, Licensed Professional Counselors, Marriage and Family Therapists, and Psychiatric Nurse Specialists.

SEARCH COMMITTEE

Many individuals will be involved in the recruitment and selection process; however, only a few will actually carry out the work. A search committee can be created to identify, screen, attract and recommend candidates. Final selection of the successful candidates can be made by either the committee, the council, the community at large or a combination of these bodies. Refer to Exhibit 11-1 for checklist of recruitment activities.

In determining committee size and membership, consideration should be given to factors such as the:

• position being filled - membership will likely differ depending on whether the community needs a physician, clinic manager, nurse practitioner, physician assistant, dentist or mental health professional;
• size of the community or existing organization - a large, diverse organization or community may want to have representation from a variety of groups;
• political climate of the organization or community - it may be important to have representation from unique groups within the community;
• ability to attract potential candidates - it would be ideal for members to have a wide range of personal contacts from which to attract potential candidates; and
• time commitment needed - depending on the difficulty of the search, committee members can plan on spending from 25 to 100 hours to see the search through to completion, as the search process can take from six to eighteen months. One person with ample time should be appointed to head the committee.

RECRUITMENT TIMING

Many providers - particularly physicians currently enrolled in residency training programs - prefer to schedule new employment during the summer months following the academic year and also for various personal and family considerations. Search committees must therefore be careful to allow for adequate lead time in their recruitment efforts. The fall of the year prior to the summer of the year when hiring will actually take place is often the ideal time to begin the process of contacting potential candidates.

COMMUNITY SUPPORT

Broad-based community support is essential to generate creative ideas for successful recruitment. The cooperation and support of the community may be one of the most important factors to attracting and keeping primary health care practitioners. The community must be encouraged to participate in all aspects of the process, from planning to follow-up. It is also important to have the commitment of key community leaders so that they will provide assistance and be available to meet with the candidates. For example, a banker might provide a start-up loan, a realtor can help find housing, and a school superintendent can answer questions regarding education if the candidate has children.

RECRUITMENT BUDGET

Recruiting primary health care professionals can be costly. The Rural Physician Recruitment Survey Report estimates that the majority of private recruitment efforts cost approximately $10,000 per physician practitioner recruited. However, experience has shown that the figures can range up to as much as $50,000. No reliable figures are currently available relative to the costs associated with the recruitment of other non-physician primary care specialists. Whatever the costs, comprehensive recruiting budgets will necessarily include the following activities:

• cost of staff time involved in recruitment efforts;
• promotional material development;
• mailing and postage;
• purchase of mailing lists;
• telephone calls;
• advertising;
• professional head-hunter recruitment fees;
• site visits;
• relocation expenses; and
• incentive packages.

Local funding sources should be explored first to secure support from community organizations and citizens. The community's willingness to raise scarce resources will be indicative of the public's future support. If local funds are inadequate, other potential funding sources such as state and federal programs and philanthropic foundations should be explored.

CANDIDATE ANALYSIS

In an earlier stage of the development process, the number and type of primary care practitioners needed, will have been determined. This task then, focuses on the type of individual that the community needs and wants to fill each position. Each community will have its own criteria unique to the individual area's needs; e.g., some areas may only be interested in candidates who are bilingual. The key screening criteria for all candidates will include their:

• qualifications; competency;
• experience;
• willingness and commitment; and
• availability.

The goal is to find candidates whose personal, professional, and environmental needs closely match what the community can provide. Consideration of the factors listed in Exhibit 11-2 will increase the likelihood of a successful match.

THE SUCCESSFUL RECRUITMENT PROCESS

From the outset, it is vital that the Search Committee understand the "Big Picture" of how the recruitment process works. Medical Search Consultants, Inc. of Overland Park, KS has identified ten (10) key steps of the recruitment process. A brief outline of each step is included in Exhibit 11-3. In order to ensure the best chances of success, it is important that the Search Committee not attempt to "short-circuit" the process by skipping some of the steps. The actual flow of these steps is further illustrated in the chart identified as Exhibit 11-4.

COMMUNITY MATERIALS

A frequent request of many candidates is "send me some information." The South Dakota Office of Rural Health identifies three types of promotional material used to attract potential candidates and inform them about the opportunity and the community itself:

• Community Brochure - is intended to sufficiently spark an individual's interest in the area to make a visit. This can be done by producing a one page fact sheet that includes a map of the area and highlights cultural, educational, recreational and financial information about the community (see Exhibit 11-4 for a sample sheet);
• Opportunity Profile - is intended to succinctly describe the practice environment and a description of the type of practitioner desired. This also should be done by producing a one page fact sheet;
• Video Tape - is intended to show both the community and the practice opportunity in a 6-10 minute video. Testimonials from the primary health care community can be helpful to solicit the viewer's interest; and
• Web site - many state PCAs and PCOs have posted community and practice vacancy descriptions on their Web sites. Be sure to check your particular state's Web site at http://bphc.hrsa.gov/OSNP/PCAWEB.htm and/or http://bphc.hrsa.gov/OSNP/PCOWEB.htm.

These materials need not be time consuming or expensive to produce. Consider using the Chamber of Commerce, Economic Development Department, local tourism boards, college students, or local television stations and newspapers in the development effort.

RECRUITMENT SOURCES

There are a number of sources available from which to recruit primary health care professionals (see Exhibit 11-6). This exhibit includes resources for the following primary care disciplines: physicians, physician assistants, nurse practitioners, certified nurse midwives, dentists, dental hygienists, psychiatrists, health service psychologists, licensed clinical social workers, licensed professional counselors, marriage and family therapists, and psychiatric nurse specialists. While it is a good idea not to limit the search to one source, your committee will need to consider the costs associated with each of the sources and the funds available for the search. Despite the sources used, it is important to be clear about what is being offered and how this opportunity can benefit the applicant. In addition, all materials should make it easy for the applicant to respond to the opportunity by including contact names and telephone numbers on all promotional materials.

Do not assume that just because someone has a job, they are not looking for one. Experience suggests that individuals may not consider a move until someone approaches them with an opportunity that represents the next logical step in their careers. Keep in mind that you want the best person for the job, not the best person who happens to be looking for a job!

A longer term recruitment strategy that has worked for many sites has been to send a clinic employee for physician assistant or nurse practitioner training. Also, the NHSC scholarship program offers federal support-for-service in training to become a physician, dentist, nurse practitioner, or physician assistant.

Assuming that your need to recruit providers is more immediate, this may be a good place to again review the capabilities of the NHSC program previously described in Chapter 1. [LINK] The NHSC is the nation's premiere recruitment and retention program for underserved populations in the U. S. As previously noted, the NHSC recruits all primary care disciplines into HPSA-designated sites. Per the guidance provided in Chapter 1, you can check into your community's designation status by querying the HPSA database at http://bhpr.hrsa.gov/shortage, as well as obtain an application for NHSC assistance at http://nhsc.hrsa.gov/application. Additionally, if your site is designated as a medical HPSA, you may also wish to explore the J-1 Visa program which waives the requirements for Foreign Medical Graduates to return to their native country in exchange for service in a HPSA. Each state has its own rules for administering the J-1 Visa program and you should therefore contact your state's PCA, PCO, or Office of Rural Health to inquire about application procedures and priorities.

RECRUITMENT METHODS

There are many ways to make potential candidates aware of employment opportunities. Exhibit 11-7 identifies those methods commonly used to reach prospective candidates. The Search Committee will need to decide the most appropriate method(s), taking into account past experiences, the recruitment budget, the urgency of the need and the community's preferences. A key decision at this point is whether or not to use the services of a professional headhunting firm. Reasons to use such a firm include:

• You do not have ongoing recruitment needs;
• Your recruitment needs are in a highly specialized area where difficult and special recruiting skills are needed; and
• You have neither sufficient time nor skill in-house.

Reasons to do your own recruiting include:

• You will have ongoing recruitment needs over the next several years;
• You want to have control over the quality and quantity of the recruitment work;
• You have sufficient time and in-house skills;
• You wish to save money on headhunter fees; and
• You are willing to make ongoing recruitment a part of your management process.

Whatever your choice - to use a professional firm or do it yourself - you must still oversee the recruitment process and be involved in crucial steps along the way that can not be delegated. Don't assume that hiring a professional headhunter will solve all of your recruitment problems!

SUCCESSFUL RECRUITMENT STRATEGIES

Exhibit 3-1 of this manual includes case studies of five primary care centers that have been particularly successful in recruitment and retention. Although each site uses its own combination of strategies based on individual circumstances, needs, and experiences, they do share some similar techniques and guiding principles.

These communities have had success primarily concentrating their recruitment efforts on the following types of candidates:

• Practicing primary care practitioners currently residing in or from the area or similar environment;
• Students originally from the area or similar environment;
• Seasoned or retired professionals;
• Practitioners who do not want to assume the financial responsibilities of a private practice;
• Nurse practitioners and physician assistants in training who are seeking clinical rotations; and
• NHSC Scholars and/or those interested in the NHSC Loan Repayment Program.

FIRST IMPRESSION

When possible candidates have been identified, the community will want to put forth a positive professional image. The initial approach to candidates will greatly influence their impression of the community and the position. Consequently, verbal and written communication with candidates is very important. The following guidelines help to make a good first impression:

• The phone contact listed on material is courteous and knowledgeable;
• Inquiries are attended to promptly;
• Written materials are personalized and friendly;
• Questions are answered completely and honestly; and
• Interested candidates receive a telephone call.

Ongoing communication by a committee member and status updates will serve to keep the interest of suitable candidates. Exhibit 11-8 is a sample letter for a potential candidate.

Once the Committee determines the best-suited candidates for the present situation, the others should be notified promptly. It is important, however, to express the possibility of consideration for future positions. We suggest the following guidelines:

• an honest approach, informing the candidate of your decision;
• early written communication; and
• keep in mind, the less said the better .

GENERAL

Once potential candidates have been identified, the following general recruitment strategies are recommended:

• In-depth research of the family's needs, including spousal employment, educational and housing needs;
• Pre-visit phone interviews with both the candidate and the spouse/companion;
• Interviews should cover everything from salary and incentive plans to call coverage and medical philosophy;
• If the site is currently operational, final candidate(s) should work at least a half-day with the medical director or appropriate health care professional during the first or second site visit;
• Focus of the initial visit should be more a social visit for the family than anything else; and
• Show off the community without attempting to hide anything.

SCREENING CANDIDATES

From the list of interested candidates, the Search Committee will want to screen out those individuals who are not a good "fit" with the position. Initial screening should take place through a resume review or a telephone interview:

• The resume review lets you quickly assess an individual's education and work experience as it relates to your community's requirements. It will let you rule out people who do not have the necessary qualifications; and
• The telephone interview is not meant to be in-depth or to exchange all the information that will be necessary to fully assess "fit" with the community/organization; however, it will assist in weeding out people who for a variety of reasons are not likely to be serious candidates. The telephone interview has an added benefit of enabling the committee to learn more about the candidate's communication skills/style, mental agility, and a brief insight into their personality and interest in the position. It also enables the committee to "sell" the community and the position if so desired.

Exhibit 11-9 identifies some of the questions that might be asked during a screening telephone interview.

CHECKING REFERENCES

Before checking references, it is important to gain the candidate's permission and to plan the information that you want to confirm from each reference. At a minimum, you will want to confirm:

• formal education/degrees;
• dates of employment;
• positions held;
• scope of responsibilities;
• achievements; and
• reason for leaving former employment.

You will also have specific questions addressing issues raised during the telephone or onsite interviews.

Attention must be paid to checking the candidate's credentials. Credentialing is something that has traditionally not been done well in primary health care centers.

The number and type of references to be contacted will depend on the committee and their need for information about the candidate. You will want both personal and professional references for the candidate. In addition to the two to three references provided by the candidate, it is important to contact individuals who have worked with or have knowledge of the candidate such as a previous employer, the local professional society or association, other practitioners or co-workers. When hiring physicians, officials should also be sure to check with the National Practitioner Data Bank (NPDB) to ascertain candidate status relative to potential malpractice issues. Information from the NPDB can be obtained from http://bhpr.hrsa.gov/dqa, (301) 443-2300 and from http://www.npdb-hipdb.com, (800) 802-9380.

Also keep in mind that given the cost of a site visit, it is preferable to conduct the reference checks before offering an onsite interview.

SITE VISIT

From the screening process it is likely that the committee will want to invite one or more qualified candidates to visit the community. The site visit is an opportunity for the candidate and the community to become better acquainted and to assess the more subjective aspects to determine a "fit." The decision to include family members, to have one or two site visits, and to pay for all or part of the travel expenses rests with the committee and will likely be driven by the recruitment budget. However, it is strongly recommended that the spouse accompany the candidate on the first visit.

The family of a potential candidate plays an important role in the practitioner's decision to work and stay in a community. For this reason, it is equally important to establish a relationship with the spouse during the recruitment process. The site visit offers a terrific opportunity for you to show the family the aspects of community life of interest to them: schools, culture, recreation, community organizations, shops, religious affiliation, and job opportunities.

Pay careful attention to planning the visit and making the necessary arrangements for the trip. Exhibit 11-10 lays out an itinerary for a typical site visit.

THE INTERVIEW PROCESS

The interview should provide ample time for the committee and the candidate to cover all the areas necessary to make a sound judgment about "fit" between the candidate, the position and the community.

The interview should also include the opportunity for the candidate to meet the current providers at the site. Not scheduling the interaction is viewed as suspicious by many job seekers. Also, it establishes a situation of distrust between the new employees and the senior employees when they have not had a chance to interact during the interview process.

• tell the candidate who they will be meeting, the roles that these individuals play in the community/organization, and a little about the backgrounds of each person involved;
• tell the candidate how much time they should expect to spend in an interview, a general overview of the things that the committee wants to accomplish and the areas of inquiry that will be covered;
• tell the candidate about the recruitment activities and projected timetable for decision making;
• arrange the interviews so that candidates will not run into one another as they are moved in and out of meeting rooms (if more than one candidate is being interviewed at the same time);
• the candidate should be introduced to the others by someone who has already had contact with the candidate; and
• allow free time for the candidate and his/her spouse to view the community on their own.

Before the interview occurs, it should be agreed among the committee members:

• who will lead the meeting;
• what questions will be asked and by whom; and
• who will speak in the committee's presentation to the candidate.

Questions to be asked of the candidate need to be prepared in advance and each candidate needs to be asked the same questions. Individualized questions pertaining to a person's unique background also need to be prepared in advance.

In order to develop questions that are relevant, the Committee needs to go back to the original criteria. The questions that are developed should be designed to determine the candidate's capabilities in those areas deemed critical to the position. Understanding how the candidate performed in the past is a sound predictor of future performance. Refer to Exhibit 11-9 for issues that may not have been covered during telephone interviews. Sample questions for the hiring entity are illustrated in Exhibit 11-11. Also, refer to Exhibit 11-12 for suggestions for the interview phase, namely, preparation for questions likely to be asked by the candidate.

During the interview process, hiring entities that are non-profit, community boards need to be particularly aware of how their own expectations may differ from those of the physician candidate whose training and prior experience may have been in a larger setting. Exhibit 11-13 illustrates some potential areas where negotiation may be necessary to arrive at mutually acceptable terms of employment.

RANKING CANDIDATES

In order to rank the candidates, it is important to go back to what the committee agreed upon as being critical in terms of experience, skills and style. Prioritize the most important criteria being looked for in a candidate. Score each candidate on his/her strengths in these critical areas. It is important to stress at this stage of the process that sometimes no provider is better than a "bad fit." Do not select a candidate out of desperation!

Each member of the committee scores the candidates separately, keeping in mind that it is the CRITICAL areas that are being measured. Experience, skills or qualities that were seen as positive, but not critical, should not be included as they could result in a candidate having a high score but not in those areas deemed critical to the success of the position. Strong candidates should be ranked "very strong" and "strong" on at least the majority of the criteria; otherwise, you do not have a suitable candidate. The chart provided in Exhibit 11-14 may be used to rank your candidates.

OFFER OF EMPLOYMENT

At this stage, you have selected the candidate of choice and are ready to make him/her an offer of employment. Typically, a verbal offer will be quickly followed by a written offer of employment. One of the biggest mistakes made by many centers is failure to clearly define their offer. Also, be sensitive to the fact that practitioners are not always comfortable negotiating contracts. At the time of the initial offer, there will be several items that will be discussed and a number of items negotiated:

• terms of employment - which specifies the duties of the position and performance expectations;
• length of employment - which specifies the contract period, timing of renewal and expectations for future contracts;
• financial agreements - which specifies the compensation package being offered;
• fringe benefits - which specifies those benefits to be offered as part of the employment package; and
• relocation support - which specifies any expenses to be covered in relation to the move and the establishment of the facility in the community.

For a detailed discussion of compensation plans, please refer to the MGMA publication entitled, Physician Compensation: Models for Aligning Financial Goals and Incentives. You may contact them at http://www.mgma.com, or by phone at 1-877-275-6462. This reference provides various examples of innovative compensation and incentive plans (which is not covered in this manual). Although the publication does focus on physicians, the issues surrounding compensation can be universally applied to other health care practitioners regardless of the setting - rural or urban.

For the development of practitioner employment contracts, please see Exhibit 11-15. It contains a "Checklist for Contracts between Health Centers and Physicians" and will give you a sample of contracting topics. The information is focused on the physician in the rural setting but it can be modified to suit other practitioners and the urban setting.

Verbal agreement should be reached with the candidate on the terms of employment prior to the offer letter being extended. The offer letter is meant to formalize the agreement and should reflect the terms agreed upon. Because candidates will not resign their current position until they have a letter in hand, it is important that the letter be sent out and received in a timely fashion.

CANDIDATE FOLLOW-UP

Recruitment does not end when the candidate signs the employment letter agreeing to accept the offer. It can take up to six months before the practitioner actually starts to work in the community. In the interim, it is important to make him/her feel a part of the community by periodically sending local newspapers, calling the candidate to update them on community activities, and forwarding announcements of his/her arrival. You will also need to work with him/her to ensure a smooth transition and a warm welcome into the community. This is a good opportunity for the community to get involved.