Trade in your specialty nurses for 'customists'
Trade in your specialty nurses for 'customists'
Here's how to streamline your staff
Corporate America in the 1990's has focused on the principles of "improving quality" and "cutting costs." Those principles are not as easily applied to home care, where technological advances are not the panacea they've been for other industries.
This may explain why more than 1,000 agencies have closed nationwide in the past year because they can no longer survive on what Medicare pays. Logic dictates that if most of your costs are in labor, then you must find ways to make your labor more efficient. One way for home care agencies to streamline their labor costs is to cut back on specialty nursing, which typically is less productive.
But if you do this, how will you maintain or improve the quality of care for those patients who need nurses with special skills? The director of Beaumont Home Care in Sterling Heights, MI, believes she has the answer: Create "customized nursing" positions.
"Many agencies went to the model of specialty programs, such as wound care, cardiac care, rehabilitation care, and infusion care," says Deborah Kleinhomer, MSN, RNC, CNAA, CHCE, director of the hospital-based full service agency that serves three counties in Southeastern Michigan.
Kleinhomer says Beaumont Home Care also tried specialty nursing in wound care, rehabilitation, and infusion for a few years. "But productivity in specialty programs is not as fruitful as it should have been, and our expenses per visit just went through the roof."
Kleinhomer decided to try something different, prompted by an article she read about mass customization of nursing.1 The theory is that just as mass production improved the quality of goods and lowered manufacturing costs, mass customization of nursing might improve quality and lower costs of home care.
Beaumont Home Care made the switch from specialty areas to mass customization, and the result has been better productivity, Kleinhomer says.
After the customization program was in place, productivity among the former specialty nurses increased from an average of 4.0 visits per day to 5.2 visits per day, a 23% increase in productivity at the same salary cost, Kleinhomer says. Eventually, the agency will have outcomes information that will show whether the customization program has improved patient care, she adds.
Here's how the agency did it:
1. Select areas to customize.
Not every specialty area can be customized. Beaumont Home Care retained specialty nurses in pediatrics, obstetrics, and psychology. However, those specialty nurses also do general nursing, so their time is more productive than if they only worked in their specialty areas, Kleinhomer says.
The agency selected wound care, rehabilitation, and infusion care to customize. The specialty nurses who stayed with the agency became "customists" themselves. Kleinhomer says their salaries did not change because they had been paid the same hourly rate as other field nurses all along. The difference was that their productivity increased because they no longer only saw patients within their specialty area.
2. Establish customization framework.
Kleinhomer outlined this framework for the customized nursing program:
· Uses "specialty-designed" curricula to provide home care nurses with an area (or areas) of "emphasis."
· Utilizes "real" disease states of patients. "I looked at what we're really dealing with," Kleinhomer says. Data showed that the agency's patients had these diagnoses:
- arthritis and fractures, 19%;
- cardiovascular disease, 17%;
- respiratory disease, 8%;
- cancer, 7%;
- wounds, 5%;
- diabetes, 3%.
"That told us where we want to put our emphasis first, so we said, 'let's do restorative nursing first,'" Kleinhomer says.
· Utilizes current staff trained in "areas of emphasis" along the disease states.
· Matches "what we need" with "what we have."
· Is RIMMS-compatible. RIMMS, marketed by SaTech Inc. of Bloomfield Hills, MI, is a scheduling software package the agency purchased. The software looks at the total population of patients and who currently is visiting them. When a new patient case comes up, the program will select the best staff person to take that case. It makes the selection based on the employee's available time and current travel pattern.
"We're just getting this under way with one of our teams, and we'll incorporate the customist into it," Kleinhomer says.
· Promotes enhanced marketability for nursing staff. "The more skills a person has, the more mobile it makes them to make moves within nursing," Kleinhomer says. "So that was our idea to promote that to the staff."
· Conceptually, it is efficient, cost-effective, and competency-based.
· Designed for easy modification as the hospital population (primary source for customers) changes. If the hospital's patient population suddenly surges in a new direction because the hospital has built a new wing or started a new program, then the home care agency could train its staff to meet that need.
3. Design the process.
The process would start with a task force. Kleinhomer pulled together the agency's field nurses and specialty nurses. Other task force members included nurse managers, an LPN, a staff development employee, and others.
Here is the process she designed:
· Research hospital and home care disease states, looking at two-year trends.
· Conduct skills assessment of current staff. "We keep a running log on every staff person, a history of what they've done in the past, and the skills they've learned," Kleinhomer says.
· Identify needs areas.
· Design program curricula.
· Match staff to program needs.
· Provide course work for experienced and novice levels, giving novices an experienced mentor.
· Investigate specialty certification requirements for future plan. "I'd like to see what nursing accrediting bodies and organizations have available so the staff could sit for a certification exam to augment their credentials," Kleinhomer says.
4. Survey staff, looking for volunteers.
Beaumont Home Care promoted customized nursing training by saying the more skills a nurse learns, the more marketable he or she will be within nursing.
"We surveyed the staff to find out what areas are of interest to them," Kleinhomer says. "If we had more nurses interested in one customized area than what we felt the population could service, then we tried steering them to another area of emphasis."
The agency has 94 full-time nurses, and fewer than half chose to learn the customized areas. About 12 nurses are customized for wound care, another 12 have learned rehabilitation/restorative nursing, and 18 are customized for infusion care.
It even worked out geographically. The agency has geographic teams, and the customized nurses are fairly evenly spread throughout the service area.
5. Hold inservices on the specialty areas.
The agency's nurse specialists, including a wound care nurse, and specialists from the hospital taught nurses in the customized nursing programs.
Each of the three customization areas were taught in one three-hour inservice. They covered the following areas:
· pathophysiology of disease;
· case studies of the disease;
· typical medical interventions used with the disease;
· what would need to be accomplished to get the best possible outcomes.
In addition, the wound care training included use of a mannequin, supplies, and hands-on demonstrations.
Reference
1. Deremo DE. Visions for the future of nursing. Images of Nursing 1996; 17:4-8.
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