2016 Spring Management Bulletin

Spring 2016 Respiratory Care Management Bulletin

Roger L. Berg, PhD, DSc, RRT-NPS
RT Instructor
American Career College
Ontario, CA
Cheryl Hoerr, MBA, RRT, FAARC
Director, Respiratory Therapy
Phelps County Regional Medical Center
1000 W. Tenth Street
Rolla, MO 65401
Past Chair
Bill D. Cohagen, MSHCA, RRT, FAARC
In this issue:

Notes from the Chair: Let’s Go Shopping

Cheryl Hoerr, MBA, RRT, FAARC

As I write this column in early March, it’s hard to believe we are approaching the end of the first quarter of 2016. Time just seems to fly these days, especially as we face the daily challenge to treat patients more efficiently and send them on their way as quickly as possible while doing all we can to ensure a good outcome.

Our field is most assuredly going to continue to evolve as health care transformation continues at a breakneck pace. So my question to you is: how are you preparing for the new challenges you will face this year? They won’t be the same challenges you confronted last year, so you will need to re-supply and acquire a fresh set of tools in your toolbox. I always appreciate a “shopping opportunity,” so allow me to point out some of the places I shop for new ideas, tools, and resources.

First and foremost . . . the equivalent of the designer outlet . . . the best of the best for restocking your tool chest . . . is the AARC’s Summer Forum. This premier “meeting of the minds” for managers and educators is a definite must for leaders who need up-to-the-minute news and information about respiratory care.

The meeting also provides an unrivaled opportunity to network with your peers to discover developing trends, discuss recent challenges, and float new ideas for evaluation by some of the best and brightest in our field. This year’s presenters have been asked to provide attendees with a concrete “take-away” for each of their lectures, the idea being that the attendee will immediately be able to implement his or her new knowledge using the take-away.

Examples of take-aways could include an ROI form to track a new business initiative, a new scheduling matrix, a template for tracking the impact of RT navigators on hospital readmissions, or a behavioral interviewing checklist. And what could be better than acquiring these take-aways at a world-class resort and spa like the Sawgrass Marriott in beautiful Ponte Vedra Beach, FL? I would encourage each of you to check out the venue and program, and then make your reservations as soon as possible. The Summer Forum occurs in June this year — a month earlier than we usually meet — so the timeline is short. I’m looking forward to seeing everyone there!

Another great opportunity to add to your toolbox is provided by the AARC Management Section. We offer a wealth of opportunities to shop for information and ideas to improve your department operations. Section members generously share their challenges and headaches on our discussion list, which allows input from other members who may have already solved similar problems. This, in turn, provides a discussion forum where everyone can learn.

As your chair, I receive a tremendous amount of help from the staff at the AARC in identifying resources that I then post on the discussion list in the hopes that they may make your jobs a bit easier. The AARC staff is also available as a resource to our section and is often asked to research questions/concerns that are posted on our list. Think of what a huge timesaver this is, and imagine if you had to find all of this information on your own!

A tool you can use to discover new ideas and information is the Leadership Book Club. If you’re thinking that a book club isn’t for you, consider this: in order to stay fresh and relevant in your position, you need a constant influx of new ideas to keep you inspired.

Our Leadership Book Club may encourage you to read a book that you wouldn’t normally pick up. Most people are creatures of habit, and that applies to their choice of reading material, too. Chances are good that the book chosen for the Leadership Book Club is one that you’ve never heard of or never considered. That means there is a new point of view and new ideas that you haven’t explored. If by chance you’ve already read the book, then you can share your insights and brilliance with the rest of us! Most of the books we’ve read have generated some great discussions and triggered some “a-ha” moments for many of us.

So start planning your shopping trip and be on the lookout for those fabulous buys. Who knows? You might get lucky and find a great bargain that will change your career! Good luck and good shopping!

Documenting Value, Not Counting Activities

Garry W. Kauffman, MPA, RRT, FAARC, FACHE
Consultant, Walnut Cove, NC

For those of you who know me, you probably realize what this column is going to be about. However, don’t skip it, because there’s a call to action at the end! For those who don’t know me, my name is Garry Kauffman and I’ve been a proud AARC member and RT since before Jimmy Carter became president. The reason I state my age and heritage is key to the point of this missive.

Back in “the day” when I was entering the field of “inhalation therapy” (apparently the expiratory phase of our services had not yet been acknowledged), the “Big 3” in terms of our department’s med-surg unit services were: IPPB, blow bottles, and oxygen (i.e., oxygen rounds and charging). This was the era of cost-minus or charge-plus reimbursement methodology. In short, the more we did, the more revenue accrued to the hospital and the RT department became one of the three largest revenue generating departments behind radiology and lab.

Life was good . . . or so we thought.

From simple to complex

Life was simple as well, in that the goal for each of us as students and staff was to get our treatments done, oxygen rounds completed, and vents “checked.” (BTW: We really need to stop using this inappropriate term, “vent check,” but that’s an issue for another column). If someone asked me what I was doing and if it was working, I would quickly show them my completed treatment card to show that I did what I was asked. And if that someone was the department director, I would show her that I completed the charge ticket. For those new to management, you may think that I’m making this up and that this is heresy. You’d be wrong on the first count but absolutely right on the second.

External consultants in ’70s and ’80s were brought in primarily to improve the charge master, increase billables, increase days cash on hand, and decrease days in AR. Inhalation therapy departments were rebadged as “respiratory therapy,” “respiratory care,” or “cardiopulmonary services” to demonstrate our broadened identity, but we continued to demonstrate our place in the health system secondary to getting the treatments done, vents checked, and oxygen charged. Again, life was simple, but we were missing the most important ingredient in demonstrating our value.

With the advent of DRGs, the health care reimbursement system was dealt a serious blow. For the first time, we were put on a fixed income budget and the growth of RT, secondary to finding more things to charge for, came to a screeching halt.

Or did it?

C-suites weigh in

Over the past few years, whenever I speak, I ask the audience two questions:

  1. Who is an AARC member? (BTW, we have work to do!)
  2. Who utilizes protocols for most of their care?

The answer to the second question hasn’t changed in decades. From AARC surveys to informal polls, less than 50% of us utilize protocols for the majority of our care. When asked why protocols aren’t utilized, the answers range from “my medical won’t allow us” to “Med Exec Committee wouldn’t approve” to “P & T Committee doesn’t want RTs to change medications.” As an aside, all of these are fixable, but then again, that’s for a future column.

Over the past four years in my volunteer role as the AARC Program Committee liaison to the Management Section, I have collaborated with four nationally recognized health care consulting companies to present a lecture and provide an interactive workshop with the Management Section attendees. I had two purposes for this: 1) they can share with us why they are contracted by the c-suites and how we can be prepared, and 2) we can show them how much we know and how valuable our services are.

I hope that both goals have been met each year, and you can ask former attendees if that is so. What I have learned from these consultants is that their measurement of our value is not in concert with what we’re thinking. They are more focused on efficiency and productivity and cost-effectiveness. While we share the importance of these metrics, as leaders, we want to be able to demonstrate our value, both in terms of the acute phase of care as well as across the continuum of care.

The disconnect

Here’s the disconnect. It’s extremely difficult to attribute the specific delivery of an aerosolized medication to reducing LOS, time in the ICU, etc. Those who have suggested this is possible need to talk with Respiratory Care Journal Editor Dean Hess and receive a tutorial on the difference between correlation and causality. For me, the biggest problem is that some of us — in fact many of us — continue to measure our value and our staff complement in terms of counting billable procedures. Do we have to be cost and time effective? Yes, but we need to ensure that we’re not broaching quality care in leaping over the bar.

Case in point: In reviewing the database for a national consulting company, I examined the productivity of more than 100 departments (note: I asked that they be blinded to me) and found an 800% difference in productivity between the best performing and worst performing RT departments. How can this be in the age of evidence-based medicine, best practice, and adhering to standards of care?

Here’s the secret: It’s all in what you count and how you count it. By using the metric of “billable procedures,” Hospital X was the best in show. However, when I substituted AARC Uniform Reporting Manual standards, Hospital X dropped to nearly the bottom of the group.

Hospital X did two things that I disagree with and I hope you share my opinion: 1) they counted whatever they could count, which included “oxygen hours,” “oxygen checks,” and “ventilator days” AND “vent checks” (double counting in my book); and even worse, 2) they stacked SVN treatments!. No.1 may be the result of just doing whatever they did decades ago, and I’ve heard from some managers that “Finance still wants us to charge.”

No. 2 is nothing short of shameful and needs to stop immediately! As I’ve said publicly, if you can name one other health care professional who provides services to two patients at once, tell me. Cardiac surgeons don’t operate on two patients at once, RNs don’t do vital signs on two patients at once, pharmacists don’t dispense two medications at once, and the list goes on. This is unprofessional, shameful, and without regret in stating this, I consider “stacking” to be malpractice.

Let the emails fly . . .

Making the shift

If we don’t count “things,” what should we count? My advice is to sit down with your teams and ask them why they come to work, what they enjoy, what they would like to eliminate (aerosolized Mucomyst and incentive spirometry are the two I hear most often), and how they explain to patients, families, friends, and neighbors the value they provide each and every day. I think they’ll give you all the metrics you need, but here are a few suggestions from me for both process and outcome metrics:

  • Percent bronchopulmonary hygiene orders resulting from RT protocol versus physician-directed therapy order.
  • Percent patients who were stabilized on the second day after admission for COPD and were transitioned to maintenance medication.
  • Percent discharged COPD patients who successfully completed your pulmonary rehab program.
  • Percent patients receiving oxygen titration (rest, exercise, sleep) via an accepted methodology prior to discharge.
  • Differences in readmission rates for COPD patients who completed pulmonary rehab program versus those who did not.
  • Percent COPD patients seeing their physician within seven days after discharge
  • Percent COPD patients receiving their maintenance medications and able to effectively administer them 90 days after discharge.
  • RT staff satisfaction before and after implementation of RT protocols.

I’ll stop at this point, hoping that I’ve stimulated some thought with regard to what we need to document versus simply counting the “countables.” If you’re not willing to make the transition from “volume” to “value,” you may want to rethink your stance because your executive team and the consultants now know what to look for. If you’re ready for the journey and needing some help, I will volunteer my time to assist you and support you in any way that I can.

We’ve been in this since the era of blow bottles and IPPB, and I am confident that we’ll be recognized as highly valued health care professionals if we make the transition from “counting” to “documenting value.”

Value Creation in Tight Times

John S. Rinck, MM, RRT-NPS, CPFT
Adjunct Faculty, Graduate and Professional Studies, Spring Arbor University, Traverse City, MI

It is not unusual for RT managers to be pressed into accepting restrictive decisions made by those above them in the organization during times of downsizing, dwindling reimbursement, and competition for cherished resources. Most strategic decisions are made at high levels beyond the direct control of the manager. Health care at all levels of delivery is under siege and is evolving through acquisitions, mergers, bottom-line economics, and strategic redefinition. In this environment, managers are challenged to reduce expenses while attempting to balance revenue, volume, and productivity.

Being asked to “do more with less” is paralyzing, temporarily freezing the manager’s hopes and outlook for growth, development, or contingency planning. Once the initial shock has worn off and reality has sunk in, skillful mastery of knowing how to prioritize the daily functions of running a department cannot be overemphasized. Patient experience, staff morale, productivity, and competitive value are sacred turf not to be surrendered in the process of pursuing organizational vision, mission, or goals.

Thankfully, evidence-based management practices appearing in the literature can help by contributing plausible solutions for managers caught in the struggle to “do more with less.” Across the fields of industrial psychology and organizational development, insightful studies have been conducted in a variety of organizations that may hold potential impact and meaning for the RT manager.

Making the most of what you’ve got

In the article, “Competing with Ordinary Resources,” the authors contend that ordinary resources play an overlooked but complementary role in broader, organizational strategic initiatives.1 Because strategy, vision, mission, and goals are established by administration, it is not difficult to understand how lower-level work units may be out of view when valued resources are up for grabs. However, by addressing and promoting the value base at the heart of individual departments, groups, and work teams, the mission and goals of the broader organization are served. Where departments, groups, work teams, and individual employees are concerned, the manager is directly involved and is in a position to leverage ordinary resources.

Leveraging ordinary resources requires a firm understanding of the fact that, by doing so, the larger strategy of the organization is served.1 It is the mature manager who can take a critical look at her human resource pool and see how individuals, groups, and teams contribute to the larger organization. For example, the manager who is able to motivate staff members or departments under his control to achieve all general requirements for compliance and competency will make significant strides in mitigating imposed limitations to operations. In so doing, managers position their departments with the internal strength they need to weather financial contraction. Department certifications, increased staff credentialing, accreditations, and robust continuing education are practical,  effective means of leveraging ordinary resources.

Thinking from the inside

Problem solving under conditions that constrain creativity gained the attention of another set of authors in “Breakthrough Thinking from Inside the Box.”2 Most managers are as capable of thinking from inside the box as they are adept at living with constraints. They are used to automatically exploring alternatives, combinations, and permutations within confined spaces.2 Through the process of ideas redesigned (within the box), obstacles can be removed that interfere with creative flow.2

Framing new ideas from within the box allows the problem being solved to be tailored to specific goals and objectives.2 This goes deeper than just playing with semantics. For example, generalized initiatives must be reframed as specifically as possible. Examples might include:

  • What resources would we have to eliminate to cut costs 10% and are there customers who rarely use those elements?
  • What is our biggest constraint?
  • How would we do things if we had perfect information?
  • Who else is dealing with the same problem?
  • Which patient needs are shifting most rapidly?
  • Which technologies have changed the most since the product was last redesigned?

The point the authors make is for managers to understand that fertile questions focus on possibilities that lead to valuable, overlooked improvements from “within the box.”

Team communication counts

Seeking innovative ideas from team members is not easy in times of rapid change. In the article, “How Team Communication Affects Innovation,” the author makes several useful observations about how the amount of communication among team members makes a difference in creativity.3 One of management’s responsibilities is to coach and direct communication and watch for the limits to which communication frequency can be applied.

Too much communication in tightly fixed, cohesive groups (groupthink) or too little communication (forfeit of essential information) can thwart creative outcomes.3 Extremes, it is observed, work to stifle originality and may limit analysis or critical assessment when they are most needed. Managers who are able to promote balance between the extremes among their team members while focusing on priorities will be in a better position to enhance innovation.

The role played by Lean

In “Bringing ‘Lean’ Principles to Service Industries,” the author makes the case that although lean is widely recognized, it is met with mixed results.4 Application of lean principles to health care cannot be overlooked. A lean operating system alters the way an organization learns through changes in problem solving, quality improvement, cost reduction, and standardization.4 With focus on efficiency, lean influence holds great interest for administrators and managers alike. By taking advantage of lean tenets, the RT manager is in a better position to leverage and distill relevant aspects of the process and apply them with reasonable success. Incorporation of lean principles will undoubtedly originate in administration and include the entire organization.

Most managers struggle with implementing a new system, fighting the general inertia that many employees experience when faced with yet another new initiative.4 The goal of lean is to open up the work process and abolish the usual hierarchies.4 Learning to do more with less can be challenging with the old hierarchy in place. However, as in all technological fields, RT managers are very interested in taking conceptual ideas and figuring out how to put them into practice. Managers must first work to create a department culture that is receptive to lean thinking, then involve staff members to redesign processes to improve flow and reduce waste.5

Enlist your “alumni”

Lastly, in “The Other Talent War: Competing Through Alumni,” the authors present a strong case for the use of “alumni” who have left the organization.6 This is an idea that is still looking for a home in many organizations. With downsizing, mergers, and retirement of boomers from RT, there are retirees (alumni) who may move on to new jobs, but many others who could act as valuable ambassadors for previous employers.6 The authors take their examples from law firms, but with major demographic changes occurring alongside rapid changes in health care, use of alumni appears to be an area RT managers should investigate as well. Many companies have more former employees in positions of influence than current ones.6

Research studies summarizing changes in the workforce and how managers are learning to cope with constraints that did not exist a decade ago abound in the literature. The studies highlighted above offer a glimpse into this subject with the intent of exposing managers to fresh ideas that may enable them to do more than just survive the changing face of health care. The heart of management is to motivate staff with ordinary resources to accomplish extraordinary things. The time is ripe for managers to accomplish extraordinary things with ordinary resources.


  1. Frery F, Lecocq X, Warnier V. Competing with ordinary resources. Sloan Manage Rev 2015;56(3).
  2. Coyne KP, Gorman Clifford P, Dye R. Breakthrough thinking from inside the box. Harv Bus Rev 2007;85(12):70-78.
  3. Yu L. How team communication affects innovation. Summer Intelligence Report. Sloan Manage Rev 2005;Reprint 46401.
  4. Hanna J. Bringing ‘lean’ principles to service industries. http://hbswk.hbs.edu/item/bringing-lean-principles-to-service-industries.
  5. Miller D, Ed. Going lean in health care. Institute for Health Improvement. 2005.
  6. Carnahan S, Somaya D. The other talent war: competing through alumni. Sloan Manage Rev 2015;56(3).

Section Connection

Specialty Practitioner of the Year: Nominations for this annual award are underway now through August 6. Use our online nominations form to nominate a fellow section member today.

Recruit a New Member: Know an AARC member who could benefit from section membership? Direct them to section sign up. It’s the easiest way to add section membership to their overall membership package.

Section Discussion List: Go to the section website and click on “Discussion List” to start networking with your colleagues via the AARC’s social networking site, AARConnect.

Next Bulletin Deadline: Fall Issue: September 1.