Patient-focused care model slashes bureaucracy

Putting caregivers in charge

With a massive reorganization project finished, the rehabilitation staff at Memorial Hospital in Gulfport, MS, are moving toward a model of care that places the responsibility for clinical decision making on the staff that provide hands-on patient care.

Already the management team has been pared down to one full-time person responsible for the entire rehabilitation services division.

This replaces a multi-layer bureaucracy that included a rehabilitation director and a department head for each individual discipline, explains Karen Clarke, RN, MSN, rehab division manager.

Under the new model of care, called the whole systems governance model, the staff work in teams. Clarke is responsible for the entire division and reports directly to the chief operations officer. There are four facilitators to whom Clarke delegates management tasks, but they are not considered line-management positions. (For more on the role of facilitators, see related story, p. 25.)

The goal of the reorganization process is for decisions to be made at the point of service, but that transformation will occur over time, Clarke says. "We are working on putting structures and accountabilities into place, but it is unrealistic to think that all of a sudden a team can make all decisions. It will grow with time with the maturation of the teams and their readiness to take on the accountability that goes along with decision making," she says.

The hospital’s philosophy is that people at the point-of-service know the most about the people they serve and should participate in the decision-making process, Clarke says.

"My role, and that of the facilitators, is going to be to provide resources and to deal with operational issues," she says.

Bracing for managed care

Getting to the point where all this change could take place was a long-term process. And it has also been an evolving process as problems had to be solved.

Memorial Hospital, a city-county facility on the Gulf Coast of Mississippi, began in 1992 to look at changing its health care delivery methods in response to the Clinton Administration’s health care reform proposals, Clarke says. The hospital is one of four health care facilities within a 15-mile radius.

"We knew that significant changes were going to occur and we needed to re-examine our hospital mission and decide how to provide care in a cost-effective type of environment," Clarke says.

At the time, there was little managed care in the area, but the administration knew that the situation was likely to change as new employers moved into the area.

Instead of cutting staff to save money in the short run, the hospital undertook a long-range plan to create teams that work efficiently in order to cut costs in the long run, she says.

Under the work transformation plan, the teams are moving toward being able to make decisions at the point of service without having to deal with a huge bureaucracy, Clarke adds.

With the help of a consulting firm, the executive team developed a 10-year plan to enable the hospital to continue providing high quality health care in a changing environment.

The board of trustees and the executive team came up with strategic goals to develop a patient-focused delivery system that would allow decisions to be made at the point of service, Clarke says. "There were departments and a pecking order and so many different labels. Instead, we wanted to organize around patient aggregates," Clarke says.

The administration challenged all departments to revamp the hospital’s organizational chart to bring together similar services to meet the needs of similar patients.

"We were told to throw the old one out of the door and think outside our box," Clarke says.

The executive team took all the ideas submitted by all areas in the hospital and included them in a new organizational chart that eliminated all the various departments and replaced them with divisions, such as rehabilitation services, cardiology, medical/behavioral health, surgical, maternal/child health, ambulatory services, and clinical support.

Because the rehabilitation staff already had experience working in teams, the rehab division was chosen to take the basic design and come up with the system needed to put it in place.

The rehab team spent nine months developing the system and inaugurated the new system in May 1996.

In the rehab division, before reorganization, there was a nursing department for the hospital, which included rehab nursing. There was a rehabilitation department with a director of rehab, a director of physical therapy, a director of occupational therapy, a director of speech- language pathology, and a director of rehabilitation nursing.

Eight rehab teams

Each of the disciplines had separate staff meetings and also attended a team meeting of all rehab staff. In addition to their discipline-specific meetings, the therapists for each area of the hospital, such as acute care and outpatient, also met as a group.

Clarke’s division includes eight teams: the inpatient rehabilitation team; the acute therapy team which provides therapy in the acute care hospital; the outpatient therapy team; the orthopedic-neurosurgical team, which provides therapy to post-operative patients in the acute care hospital; two off-campus physical therapy clinic teams; the skilled nursing facility team; and the rehab administration team, which includes Clarke and her secretary.

In the entire hospital, only three assistant administrators were not offered other positions when their jobs were eliminated. In the rehab division, no one lost his or her job, but all the discipline managers and a number of seasoned therapists left. Because what is now the rehab division includes employees who once were in other departments, it’s difficult to compare the number of employees now and before the reorganization, Clarke says. For instance, in the past, staff from departments such as environmental services, distribution, admissions, and food and nutrition worked in rehab services but were assigned to separate departments. Now, they are cross-trained and assigned to specific rehab teams. This means that the rehab division has gained employees, while the core department has lost employees. (For more on the hospital’s cross-trained staff, see related story, p. 24.)

Staff’s skill level improved

The number of licensed staff has remained the same or increased, Clarke adds. Because the unlicensed staff are now cross-trained, the skill level of the staff has actually increased, she says. In addition to nursing and therapy, all staff who work on the unit are assigned to specific teams. Some positions are combinations of previous jobs. (For details on new job descriptions, see related story, at right.)

For the first year of the new structure, the rehab service line operated with the same quasi-discipline-specific departments until the design committee developed teams based around specific patient populations.

The staff went through a transition period where the departments were not officially gone, but people were being moved to their teams. In May 1996, inpatient rehab "went live" with the new organization, and the discipline-specific departments were officially abolished.

"Deciding how to group the team was the most difficult part. It’s so easy to put a reporting structure together when you are discipline-specific, but it’s really frustrating and confusing when you report by teams," Clarke says.

The committee found it fairly easy to designate specific teams for the SNF unit, the neuro-ortho surgical nursing unit, and inpatient rehab.

The difficulty arose in deciding whether to group the other therapists according to the patient populations they treat or the area of the hospital in which they serve. The committee finally decided to group those therapists according to those who work primarily in the outpatient setting and those who primarily work in the acute hospital.

"There is a lot of overlap between the therapists. Even though they belong to specific teams, they sometimes rotate through the different areas of the hospital to ensure coverage seven days a week," Clarke explains.

After the reorganization, shifting therapists to cover changing patient populations provided the biggest challenge, Clarke says.

"Even though each physical therapist belongs to one treatment team, they are also a part of a bigger team, where all the physical therapists still have to cover all of the physical therapy needs," Clarke says.

Providing coverage to other areas of the hospital for therapists who are sick or on vacation was simple with a discipline-specific department but not so easy under the current organizational plan, Clarke says. "We don’t have a therapy director to set up the schedules. It allows people to get together outside their regular routine and figure out how to cut and paste their day to best cover the area that needs it," she adds.

[Editor’s note: For more information on Memorial Hospital’s re-engineering project, contact Karen Clarke at (601) 865-3106.]