Clint Maun, CSP
In today’s healthcare organizations, it’s apparent many things are becoming capped or stifled. Competition has increased and payment and payor source relationships have become capped making it difficult for today’s healthcare organizations as they move into the managed care arena. In addition, we’ve been given the challenge to manage our businesses under a new set of tighter regulations and requirements. This has caused many to retool/reengineer their efforts. Competition for staff and the ability to retain is more difficult than ever. With all these forces working it is fair to say it is a tougher business environment today.
There is good news. There still remain great opportunities if we look at an area that has been untapped - human productivity. Sixty percent of the bottom line of the profit & loss statement of a healthcare organization is directly related to human resources/labor/payroll (direct and indirect costs). This 60% is still being managed in ways that worked 10 to 15 years ago, but is not now possible for success into the next century. It is possible to unleash productivity within this 60%, thereby sending the organization into the new era of "tougher" healthcare with greater opportunities.
To achieve this success you must review some of the systems in place that can be changed to ensure it is possible to unleash productivity. The first step in unleashing productivity is to take a look at the systems that develop work schedules. Many organizations have not moved to self-scheduling, which empowers coworkers to be involved in setting the schedule for their unit. You may be using outdated shift and hour per patient day models that don’t fit today’s new array of customers, services, admissions, discharges, etc. This area of self-scheduling and self-involvement allows for tapping into the team’s assistance in promoting attendance as a way of life in a workday, rather than the high amount of absenteeism that is creeping into many organizations.
In fact, there remains silly systems that centralize scheduling to the point where the scheduler is in a negative impact position by granting favors, making promises and allowing people to be dysfunctional in their work pattern. In other words, some individuals are able to call in one day but work another day in a two-week period to receive overtime for that week to make up for pay they lost by calling in sick. Somehow the system may reward people who call in sick by allowing them to be available for extra work when needed. These systems of dysfunctional centralized scheduling cause the team to not care about the schedule other than how it affects themselves. It sets up "we/they" processes and promotes absenteeism.
The organization also needs to look at how it develops an on-going process of hiring, includes peer involvement in hiring, orientation processes and the ability to develop sound retention strategies. When this is overlooked, we’re finding many become complacent about the use of pool or agency help. They also become codependent on outside staffing sources. They believe that it’s a "no hope" situation to keep help and thus puts extra costs into their overall expense budget to cover this high cost of turnover (this includes extra orientation and training/certification classes). There are also extra personnel on board for on going training and in-service for new employees because there is a constant revolving door. The organization never gets at the issues associated with morale and motivation, which are instrumental in retaining staff. They spend their money unwisely in developing unsound wage/benefit packages because they believe it will make the difference in retaining employees. These costs stifle organizational creativity and productivity and also lead to another example of parent/child handling of critical problems. This parent/child handling of problems affects productivity.
To be successful and get all the work done in a day, it is outdated to use the old model of assigning work. The old model used in many healthcare organizations is to take an assigned duty list and pass it out to each unit staff member. Each staff member is then assigned an equal number of "customers" to take care of. They are expected to get all the work done, ask for help when they need to, but basically get it done by the end of eight hours. One of the problems with this format is that is doesn’t allow for any self control systems to be developed for coworkers.
We believe there should be an agreement between coworkers and the unit manager on what needs to be accomplished by a certain period of time. Therefore, if there are 20 items on a checklist for each customer, by 8:30am in the morning if we start a shift at 7:00am, where should we be on the checklist? If everyone agrees we should be at least on number six then the coworkers should report to the unit manager where they stand at 8:30am on that checklist. They are either on item number six for each of their customers or they are behind or ahead. They can then set up another reporting system that develops self-control at 10:00am or 10:30am. Another can be developed right after lunch and one by the end of the shift. In doing this, you allow the unit manager to stay on top of what is going on with that unit and not wait until the end of the shift to hope to hear everything got completed.
It also develops responsibility on the part of the coworkers to realize a certain rate of work done in an effective way. In this model you can’t report on things when they’re not done correctly or not done at all. That’s called fraud. You are expected to have work done in an effective and efficient manner. This self-reporting system is highly desirable for new employees. They love to find out where they stand. Good employees like to be able to report they are on schedule or ahead of schedule. Your disruptive or troublesome employees don’t like this system because it places accountability on them. They don’t like any system you try to develop, so don’t worry about them.
Develop a system from a positive standpoint and hold people accountable to complete the work they say they can do by a certain time. If it can’t get done, and the whole unit is behind by a certain time of the day, then the unit manager can make the necessary adjustments to ensure success for the day. You don’t have to wait for the end of the shift to see if you are successful.
In association with the paragraph above on self-reporting, it is also important for individuals to have some ownership in their work assignment. Rather than handing out an equal number of customers to each co-worker, it is possible for the unit to develop an equity-based system for each customer on the unit. Have the employee sign up for "care points" that represent the amount of work they want to be responsible for.
By this we mean, the unit develops a system to profile who’s the toughest customer on that unit (that person receives a 10) on down to who is the lightest care person. They assign care points to each of the individuals on that unit and therefore, make it possible for a co-worker to say "I will take 9 customers that have a total care point value of 78", another individual could say they will take "13 customers that have a total care point value of 78". This eliminates the need to have an equal number of customers responsible to each individual. It also allows the co-worker to take the type of customers they are best suited to handle.
If a person can take a greater amount of lighter care customers in their portfolio for the day they should feel like they’ve got the ability to get that accomplished. It gets out of that everything has to be "fair" or equal syndrome. This fairness concept haunts American healthcare because it allows us to be in the parent/child model of delivering changes in service delivery when people don’t think things are fair. The problem with that is it allows the people who think things are unfair to have the loudest voice.
Under the care point structure, a process can be developed i.e., over time where individuals who take more care points receive certain advantages, certain days off or additional compensation. It is also then possible not to load down new coworkers with care point loads they can’t achieve which would end up running them off. This process delivers a reengineering of the work assignment and workload process on a daily basis. It puts accountability and responsibility on the team and makes the unit managers and team responsible for the success of the unit’s activities on a daily basis. It allows us to empower unit managers and charge nurses and take responsibility off the Director of Nursing (DON).
In many healthcare organizations, the DON is the only person who makes decisions for implementation of activity. We find when you couple these programs with hiring practices on units, coaching and disciplinary actions by peers and unit managers along with the true decentralization of work effort, you have an opportunity to unleash productivity at a tremendous level. In our case study program of 40+ facilities, we found productivity increased between 25% and 32% on a daily basis.
The process must be customized for each facility. It has to be worked through for the facility to own this process, but it allows them to move to the next level with the belief they can do something to make a difference on a daily basis, and achieve their results to be successful. This is tremendously important to today’s healthcare facilities as they plan for a tougher healthcare environment in the future. We believe from the case studies we’ve worked with and have been a part of in our consulting approaches, that this type of process provides a "light at the end of the tunnel."
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