Jack Fried, MA, RRT, Director, Respiratory Care and Neurodiagnostic Services, St. Mark’s Hospital, Salt Lake City, UT
It has often been said that the only thing changing in health care is change itself, and that change is now occurring faster than ever. Perhaps the people most affected are those in the C suites, senior executives under the greatest pressure to reduce costs while improving quality. They are the ones hearing workers’ demands for more personnel to care for sicker people, more equipment, and higher salaries. They are the ones feeling the impact of accountable care organizations and other new proposals to reimburse care, usually at lower rates.
Then there are department leaders such as us, who hear the needs of our staff members while being subject to the demands of senior executives. The staff has to provide the care on which organizations are judged. The primary task of department leaders is to deliver quality patient care with limited resources. It is often difficult to get bedside clinicians to see the challenges from societal demands for reduced health care costs, but it certainly is not surprising. After all, we want them to focus on quality care and make the hospital visit as good an experience as a hospital visit can be.
In short, the challenge for department leaders is to align staff priorities with the organization’s needs to survive and achieve its mission. That means we have to motivate people to perform and behave accordingly.
Does it work?
Almost all managers have been trained on and introduced to Maslow’s Hierarchy of Needs. Aside from the fact that physiological needs now seem to include the Internet, nothing much has changed in management education since. Frederick Herzberg’s last paper, “One More Time: How Do You Motivate Employees,” published in the January 2003 issue of the Harvard Business Review, discusses reduced time spent at work, often referred to as work/life balance; benefits; sensitivity and communication; job participation and enrichment as opposed to job enlargement; and, of course, coaching/counseling.
Good ideas right? As Herzberg points out, they really haven’t worked. This is not to say these things shouldn’t be done, but they have had very little payoff even when enhanced by advances in management science developed since Herzberg’s death. The problem is that a lot of management science has come to be sarcastically referred to as “management flavors of the day,” and that does not bode well for engagement.
One of my favorite interview questions was to ask each applicant how I could motivate him or her. Almost everyone told me to give them the necessary skills and tools and then, essentially, to get out of their way and let them do the job. Then someone told me I couldn’t motivate him, that he was already motivated.
So now the question is, can you motivate someone who is unmotivated or simply unmotivate someone who is motivated? Forty years of hiring and firing have taught me that both are true. Dealing with the unmotivated employee is easy; you fire the individual. You don’t look very good for making a bad hiring decision, but that problem is solved and your staff is usually appreciative.
As for the motivated, we like to tell people they are empowered. Don’t you do the same? “Well, of course, they’re empowered,” you say. “We just want out-of-the-box thinking.” Really? Even if it doesn’t work?
Staff know best
A common topic on our Management Section discussion list on AARConnect has been the use of personal electronics while on duty. We know people use them to conduct personal business, just as they once used hospital phones. The problem is the frequency with which people use their personal devices to get their work done. Nurses and therapists text doctors and one another, often against hospital policy, meaning clinicians are being insubordinate as they care for patients and get their work done. Work flow and technology need to meet clinicians’ needs as much as they need to meet the needs of billing professionals and quality management data collection.
Forty years as a director and I’ve seen this over and over, both in hospitals where I have been the director and in hospitals where I have worked per diem: staff doesn’t like a certain nebulizer or circuit, but we keep using it because it’s on contract. Better yet, the sales representative says it works and even has proof from the company engineers.
Now that’s a good motivator — staff cannot even choose the products they use. Sure, most disposables work well, but is it worth fighting over 100 foot rolls of corrugated tubing staff say are too rigid and pull the aerosol mask off the patient’s face? What about those nut/nipple adaptors said to be too blunt for the oxygen tubing to stick?
Another recent topic of discussion on AARConnect has been recognition awards. Does the Employee of the Month award make up for having to use products staff don’t like? We give them plaques, but they can’t choose corrugated tubing or a tubing connector?
Purchasing contracts are a necessity to keep costs under control, but the variances discussed above are not going to lead to bankruptcy or set a precedent if you use common sense. In fact, the last statement about the corrugated tubing came from a corporate supply chain manager. The organization where I now work is unequivocally the most successful of the five in which I have been a director. The senior leadership team is so focused on employee input that directors are required to track employee suggestions and either implement them or have a good reason for not doing so.
Back to basics
Let’s get back to basics. Listen to people and hear what they say. If there is no reason not to do what is suggested, do it. It’s true that 1600 people can have 1600 opinions, but you can use common sense. Better you should keep the plaques and complement the person and, if possible, do so in public.
One of our corporate executives once said that if you’re having trouble finding the rights words, just say it. It’s hard to ruin a complement as long as you are sincere. If the person works weekends or nights and you won’t see him for a while, call him at the hospital.
Employee awards are great when they are sincere. Do them too often and they lose their meaning. If you’re wondering who to nominate each month or quarter, your staff is probably wondering whose turn it is. That may be a sign your award has no meaning. A sincere complement almost always has meaning. It isn’t that difficult. Take it from someone who still feels uncomfortable in a lot of social situations.
It will always be difficult to get people to accept change, especially grumpy old people akin to me. People have their comfort zones, and many people have been through failed transformations. I am a good example of a cynic whose past employer went through a merger and re-engineered. Neither hospital exists today. Another hospital spent over $6 million adapting a patient focused care model it soon undid. Now we have to change to meet the demands for quality care and reduced cost. We better figure out how to engage our clinicians in these endeavors.
Here is my idea: focus on patient satisfaction, physician satisfaction, and employee engagement. Then use common sense controlling expenses. Keep it simple.
Richard Ford, BS, RRT, FAARC, UC San Diego, San Diego, CA
In the late 1940s, respiratory care practitioners emerged as a result of new technology and the specialized nature of the equipment and procedures related to treating patients with pulmonary disease. By the late ‘60s respiratory care departments were becoming the norm in acute care hospitals across the country. Health care expenses at the time were well under 2% of GDP, but with the federal government creation of Medicare in 1966, they started to consume a greater portion of the U.S. economy.
Reform enters the picture
As costs rose, so did efforts to reduce them. Respiratory care has been no stranger to these health care reforms. In the early ’80s the prospective payment system shifted inpatient services from a revenue center to a cost center. Considering 75% of the respiratory care department budget is labor, programs were developed to better manage staff productivity, and time based systems were created to determine the number of staff needed.
The AARC Uniform Reporting Manual became the gold standard to establish and support the management and growth of RC staffing programs. With cost centers, the less performed within a patient’s hospital stay, the greater the margin. Considering the importance of reducing expenses by ensuring only medically necessary interventions were provided, patient driven protocols were created, again, with the help of resources made available through the AARC. Such programs manage the utilization of services by empowering the respiratory therapist to initiate, refine, and discontinue the treatment plan based on evidence-based and medical staff-supported guidelines.
Successful departments over this period used a data driven approach to staffing and managing resources; however, they also needed to demonstrate to hospital administrators the unique value of respiratory practitioners. We exist today because we provide high quality care that is efficient, safe, and delivered by competent caregivers. And in many cases costs are reduced as a result.
ACA ushers in new opportunities
While the reforms of the 2012 Affordable Care Act (ACA) mandate departments maintain such an approach, they also provide new opportunity to demonstrate value. The ACA withholds a portion of Medicare payments from hospitals while giving them the opportunity to earn a portion of that back or be penalized further. Metrics that impact total reimbursement through the ACA are related to clinical outcomes as well as customer satisfaction.
One out of five Medicare patients is readmitted to the hospital, costing the system over $41 billion. The Readmissions Reduction Program provides the greatest opportunity for the respiratory department to impact the hospital’s bottom line. The program is inclusive of acute MI, heart failure, pneumonia, and COPD and is based on all cause readmissions within 30 days. Beginning in FY 2013, hospitals with higher than expected readmission rates were penalized. In 2017, 3% of Medicare revenues will be at risk.
Prior to the ACA, the hospital administrator would reduce expenses through consolidation of mid management, salary freezes, reductions in workforce, and pushing productivity. The ACA keeps these issues on the agenda, but provides a new focus on improving clinical outcomes and keeping patients satisfied with the services provided. Keeping patients out of the hospital requires a multidisciplinary approach that involves hospitals, primary care physicians, caregivers inclusive of respiratory therapists, and community-based care providers. The RT is in an ideal situation to:
At UC San Diego we have been in the process of implementing the early stages of this program over the past year and the result has been a reduction in COPD readmissions. We were trending as high as 27% before the program and now are running at a rate of 17%. Providing these services is estimated to consume $180K-$200K in salary per year. These costs are offset through a readmission avoidance penalty reduction estimated at $210K, as well as another $429K saved through implementing protocols specific for COPD that decrease treatment variability and length of stay and have already demonstrated a $235K decrease in costs through medication substitution and management.
The ACA also brings new roles for therapists in managing ventilator-associated conditions. By implementing weaning protocols and measures that can reduce ventilator complications and the length of time a patient is in the ICU, we may also affect the bottom line. Challenges exist to save on equipment, supplies, and medical gases as well, and this is creating new opportunities for manufacturers and suppliers to work with RC directors and their physician counterparts to ensure efficient, effective, and appropriate use at the lowest costs.
We’ve done it before, we can do it again
The ACA is here to stay, so congratulations to the early adopters of innovative programs that bring new value to the profession of respiratory care. And to those who have not yet responded, what are you waiting for? Directors have weathered the storm before using tools and resources made available through the AARC, such as the Uniform Reporting Manual, Clinical Practice Guidelines, Competency Assessment and Protocols manuals, AARC Benchmarking, AARC Leadership Institute, and the sharing of real time information through AARConnect, webcasts, and the Summer Forum and AARC Congress. We can do it again.
Jason R. Rasch, BS, RRT, Clinical Supervisor, Respiratory Care, St. Luke’s Hospital, Duluth, MN
What will they say about you when you swipe out for the last time? How will you feel during that final, lonely 3½ block walk to your parking spot?
I am hoping you can say you made a difference. It does not have to be anything monumental. There are many ways to make your mark. You can be the therapist who listens to your patient’s stories a little longer than most. You could be the therapist who takes an extra moment or two with the RN who paged you because she needed some help with a patient.
It takes a special type of person to get into health care. If you just want to go through the motions, go get a job on an assembly line somewhere. If you want to interact with others and help get people back on their feet, then take your job seriously. Take it seriously so others will too.
Respiratory care is still quite new to the health care field. For instance, we are centuries behind the field of nursing. Nurses have been here since the first offspring plopped (I think that is a nursing term) out of his or her cozy womb.
I don’t want to spiral too far out of control here, but respiratory care has only been around for a few decades and we are still trying to find our true identity. Do we belong in the critical setting? The clinic? An asylum? I have intubated in a trauma setting, instructed someone on how to use an incentive spirometer, and babysat a patient while the RN called the doctor. I found my worth in all of those scenarios as each was an important event in the patient’s stay. Sure, some are a little more exciting than others, but they are all important. Yes, even the IS instruct. If we do not take our job, our whole job, seriously, why would anyone else? I have been screamed at by a physician and been treated like dirt by other staff. In the long run, it is how we view ourselves that will ultimately show health care where we belong.
The point is, there are a lot ways to go about patient care, but we all want the same outcome. Do your thing, people. Communicate with all staff and be the bigger person. Always be the bigger person. We have but a small portion to take care of out of the patient’s whole. Let’s take pride in what we do and perform to our highest level. Who knows, in another million or so years we may be at the top of the health care food chain.
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