Agency restructures as part of QI project
Agency meets IPS goals, sails through survey
Sometimes the best results come from a quality improvement process that begins with home care managers taking a long look in the mirror.
Parmenter VNA and Community Services in Wayland, MA, managers took that long look at their own reflections and decided they could best improve their agency’s customer satisfaction, quality, and utilization by changing their own jobs.
"We wanted to make the managerial part a little less top heavy," says Marilyn Bonkovsky, RN, clinical manager for home care, hospice, and CQI for the agency which has 24,000 visits a year.
The agency began to look at restructuring its management in mid-1997. Some people felt the agency’s management structure could be improved for better efficiency and use of managers’ time and talents, Bonkovsky says. "We were looking at implementing some changes when the word of the interim payment system (IPS) came down. We added some things and saw that what we had was helpful, but we needed to take some further steps."
Change can be good
Jobs changed for everyone at the agency’s top. And the agency has been very successful in achieving its goals as a result, Bonkovsky says.
Here’s just a few indicators of that success:
• The agency’s utilization rate for Medicare clients in 1997 was an average of 47.8 visits. The agency reduced that to an average of 33 visits in 1998, a 33% reduction.
• The agency’s referral numbers increased 7% over the same period.
Best of all, quality of care did not suffer as a result of the reduced utilization, Bonkovsky says. The agency was surveyed in the fall of 1998 by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, and Parmenter VNA received accreditation with commendation.
Also, a patient satisfaction survey taken in the third quarter of 1998 shows a 92% satisfaction level, which was an increase over the roughly 86% patient satisfaction reported for the fourth quarter of 1997.
In addition, the agency’s fund-raising and grant revenues increased 120% over the same year.
Bonkovsky explains how the small agency embarked on and succeeded with its restructuring project. Here are the steps taken:
1. Managers assessed their own talents, skills.
The agency’s eight managers met in a half-day workshop to start the quality improvement process. They started with the agency’s current organizational chart and analyzed it, using the Nashville, TN-based Health Corporation of America’s FOCUS-PDCA process improvement model. (See February 1999 issue of Homecare Quality Management for a description of how the model works.)
Managers created an inventory of their organizational skills and leadership goals. "We listed what we thought we currently had and what we needed in the future in order to improve our organization," Bonkovsky says.
The inventories covered a wide range of skills, from diplomacy and coaching organizational skills to leadership roles of score keeper and absentee ruler. (See organizational skills inventory and leadership role inventory self-evaluations, inserted in this issue.)
For each attribute, managers rated themselves according to a scale of their personal skills being at the top, middle, or bottom. This way, they could each see their own strengths and weaknesses. The management committee tallied these individual responses and produced a bigger picture of the agency’s strengths and shortcomings.
At the next meeting, the managers received handouts listing the tallied items, which listed with "Xs" how many managers had listed a particular attribute on the inventory sheets.
2. Managers identified problem areas.
The tallied inventories and highlighted some areas that the agency needed to make a priority. They also opened up the discussion about what systems work for the agency and what doesn’t work.
"It was very time consuming," Bonkovsky says. "We talked about internal support services across all programs."
In all, they came up with 20 areas that posed problems to either leadership or organizational structure.
Their next step was to create an ideal organizational chart. Each manager created one and turned them over to the executive director and assistant director who put the eight individual charts together to create one new chart.
Next, managers discussed the agency’s clinical and supportive/preventative programs, and areas of future development. They also talked about ways to make their own jobs more manageable and about how to add responsibilities to various management positions. Plus, managers addressed how to develop growth opportunities for the staff and how to develop supervisory leadership skills in the areas that were identified as lacking.
"We needed to clarify authority and responsibility to improve decision making so there would be an authority and accountability that went with that," Bonkovsky says.
Managers worked on some of these issues and came up with ideas between meetings. "An awful lot of work was done between each session," Bonkovsky recalls. "We made good use of the time by preparing ahead each time."
3. Managers discussed solutions.
They brain stormed to find solutions. For example, the managers decided management jobs could become more manageable if managers would make decisions without first talking to several other managers.
"If we could clarify areas of responsibility and authority and accountability we could be more efficient in decision making," she says.
They decided to set up regular meeting times for people in management to discuss specific projects and areas of concern. This replaced the former practice of simply having managers run to their supervisor every time they have a question, Bonkovsky says.
"This makes better use of everybody’s time, and it’s not as though you couldn’t talk to someone if you needed to, but you organize your time better," she adds.
Look for opportunities
Bonkovsky says the change in the agency’s decision-making process means that managers now take greater responsibility for making decisions. For instance, as clinical manager, she might discuss a particular hiring decision or a change in policy or procedure with other employees. Now, Bonkovsky makes the final decision without necessarily seeking a consensus. "I would make the final decision if there’s a difference in opinion," she says.
"Everything doesn’t have to be a group decision or group consensus, and that cleans things up a bit," she adds. "Along with that is the responsibility. If you make the wrong decision, you have to live with it."
For another solution, managers decided to increase their leadership skills by looking for opportunities to lead and learn, such as joining statewide committees and attending meetings where they might interact with other home care managers.
4. Managers began new jobs and roles.
The biggest restructuring change was to assign managers new responsibilities and roles.
Here are some of the role changes the agency made:
• The executive director and assistant director traditionally shared responsibilities and work. This led to duplication of efforts. Now, the assistant director handles all the day-to-day managerial tasks, and the executive director focuses on one of their identified areas of concern: fundraising efforts.
"One thing we needed was a big capital campaign. The executive director began to work with the board to get this off the ground," Bonkovsky says.
That turned out to be an extremely fruitful change. A year after the change, the executive director helped to increase the agency’s nonoperating revenues by 120%.
• The agency created a position of clinical care coordinator to manage the agency’s case utilization. The coordinator is an experienced registered nurse whose job is to monitor and evaluate the utilization and appropriateness of clinical services.
"When we saw IPS coming down, it became extremely clear to us that we had to address finances," Bonkovsky says.
The new reductionism
Some managers heard about the role of a clinical care coordinator at a home care program on IPS, and the concept seemed to fit the agency’s needs.
Instead of hiring someone new to take over this position, the managers decided to have one of the current clinical managers switch roles. The agency had a clinical manager for hospice and one for home care. The change meant only one clinical manager would handle both hospice and home care, and the other clinical manager would become a clinical care coordinator.
The clinical care coordinator’s responsibilities include:
• collaborating with the intake coordinator;
• admitting nursing clients and developing a plan of care in collaboration with the primary nurse;
• facilitating on-going evaluation of agency clients for appropriateness of services;
• coordinating with the clinical manager and scheduler to assure the delivery of adequate and appropriate services to the client;
• developing or selecting clinical outcome measurement tools;
• implementing clinical outcomes;
• assisting with orientation, evaluation, observation, and instruction of clinical staff;
• assisting in planning and implementing clinical inservice programs;
• participating in quality improvement activities.
The change resulted in the agency’s 33% utilization reduction.
Bonkovsky says the agency also altered the way it approaches new home care cases by hitting hard at the beginning with many services, then reducing visits after the first few weeks. "Now, when patients need the most help, we give them the most services and then ease off."
At admission, the clinical care coordinator explains to patients how the agency will approach their care and how the patient should be able to manage alone after a certain number of weeks. "This way, we feel we have a very good approach to patients so they know what to expect from us," Bonkovsky adds.
5. The agency streamlined services.
"I think the tendency for a while in home care was to be an agency that could be all things to all people, to have one of every service," Bonkovsky says. "We were trying to develop a psychiatric nursing program, wound care program, maternal and child health, and on and on."
During the restructuring meetings, managers decided to stop diversifying because some these programs were too expensive. For example, they cut the psychiatric nursing program altogether and didn’t replace the wound care nurse when she quit. If the agency needs a wound care expert, there are contract resources available. Instead, the agency now focuses on only a few specialty areas, including the maternal and child health program, rehabilitation, and oncology nursing.
Likewise, managers decided to reduce the agency’s geographic area, acknowledging that it’s not cost effective to drive long distances for a few clients that could be handled by some agency closer to their homes.
Bonkovsky says the restructuring process was time-consuming and difficult, but has been well worth the effort. Besides resulting in some positive financial and quality outcomes, the effort enabled the agency to direct its attention on some important long-term plans.
For instance, the agency now is a partner with a developer to start an adult day health program, a residential hospice house, and an assisted living program.
"We’ve decided to put our energies in those directions, and cut bait on things that were not working and looked like they’d take a lot of time and would not be cost effective," Bonkovsky says.
Sources
• Marilyn Bonkovsky, RN, Clinical Manager for Home Care, Hospice, and CQI, Parmenter VNA and Community Services, 266 Cochituate Road, Wayland, MA 01778. Telephone: (508) 358-3000.