Hospital reduces licensed staff; outcomes stay high

Cross-trained therapy techs are key to success

Rehabilitation Hospital of Indiana (RHI) has shifted its staff ratio from 80% licensed therapists in 1992 to 45% licensed therapists in the acute rehab program today. Despite the decrease, its outcomes and patient satisfaction remain high.

RHI made the staffing changes as part of an initiative to reduce costs without compromising patient care, says Donna Cameron, chief operating officer for the Indianapolis hospital.

"As health care providers today, we are looking at multiple ways to become more cost-effective while providing quality services to meet patient needs and outcomes," she says.

The management staff decided to make the process incremental and adjust the staffing model through attrition. Key to the success of the staffing changes was establishing a comprehensive training and competency program for therapy techs.

The hospital hired therapy aides who were trained as discipline-specific techs, then cross-trained to become therapy techs. The techs are assigned to specific disciplines but are trained so they can float to assist other disciplines when needed. Management made the decision in 1995 to shift the staff mix and set an initial goal of 70% therapists, 20% assistants, and 10% techs. The goal changed each year to include a higher percentage of unlicensed staff.

No one was fired, although a number of staff resigned over time for various reasons. (For information on how recruiters capitalize on upheavals in a rehab program, see story, p. 90.)

"We made the decision to evolve the staffing model so we could refine the process as we did it. People were already feeling concerned about their employment and the way they practice. We didn't want them to fear they wouldn't have a job," Cameron says.

RHI started the change process in 1995. It took about 18 months to make the shift. "When we had a therapist vacancy, we evaluated whether the position could be filled with a therapy assistant or a tech. It varied based on where the vacancy was, but we kept in mind that we had made a conscious decision to shift the staff mix."

The mix varies across different programs and levels of care. In the acute program, for instance, there are about 45% therapists, 30% assistants, and 25% techs. The hospital also shifted from a system in which each therapist had a caseload of patients to one based on staff productivity. The number of patients each therapist treats depends on the needs of the population.

"The number of patients a therapist is involved with can vary quite a bit. One therapist may have fewer patients of one diagnosis that has greater needs while another may treat a much larger number of patients in a diagnosis that needs less treatment," Cameron explains. For instance, a therapist in the acute brain injury program may treat fewer patients than someone who treats orthopedic patients.

The management set a productivity standard of an average number of billable quarter hours per day per full-time equivalent.

RHI opened in January 1992 as a joint venture of the two largest not-for-profit acute care hospital systems in Indiana. It includes 66 inpatient acute rehab beds, 22 inpatient subacute beds, comprehensive outpatient services at the hospital, a comprehensive outpatient rehabilitation facility, and a home care agency.

The hospital has always had physical therapy assistants and certified occupational therapy assistants on staff, Cameron says. Before the changes, however, the few therapy aides were used for tasks such as setting up a treatment session and cleaning afterward.

At present there is no designation for an assistant in speech. The hospital has a master's-level speech pathologist and a speech tech.

RHI started the shift to rehab techs by hiring more aides and putting them through discipline-specific training to be occupational therapy and physical therapy techs. The training was developed by the hospital's clinical educator with input from the therapy staff.

Because of state licensing laws, speech techs must be registered under the licensure of a speech pathologist and be clinically supervised by that speech pathologist.

"We started off with a few individuals who were therapy aides, but they were not extending a therapist. You can't just flip a light switch and expect them to be competent and prepared for a new role," Cameron says.

RHI started with aides, then trained occupational therapy, physical therapy, and speech therapy techs who went through discipline-specific training. The therapy techs then were cross-trained so they could assist all three disciplines.

Typically, the techs still operate within one discipline. The hospital still has some discipline-specific techs who eventually will go through the cross-training process. RHI doesn't plan to change the therapy staffing ratios at this time.

"Right now, our staffing model is meeting our needs. But as change-oriented as the health care environment is, I am keeping an open mind to any other changes," Cameron says.

Now when a vacancy occurs, the management team evaluates how it should be filled. "We are evaluating all vacancies, but we currently are operating at a therapy staff mix we have chosen."

The hospital has always monitored outcomes, lengths of stay, and patient satisfaction. All quality indicators have remained strong with the staffing changes, Cameron says.

[For more information, call Donna Cameron at (317) 329-2225.]