Patient-focused care slashes bureaucracy

Decisions will be made at point of service

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

The redesign replaces a multilayer bureaucracy that included a rehabilitation director and a department head for each individual discipline, says Karen Clarke, RN, MSN, rehab division manager.

Under the new model of care, called the whole systems governance model, the staff works in teams. Clarke is responsible for the entire division and reports directly to the chief operations officer. She delegates management tasks to four facilitators, but they are not considered line managers. (For more on the role of facilitators, see story, p. 115.)

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."

The facility’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.

Memorial Hospital, a city-county facility on Mississippi’s Gulf Coast, 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 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 the situation was likely to change, particularly as the casino industry moved to the Mississippi coast and brought in employers accustomed to managed care.

Instead of cutting staff to save money in the short run, the hospital undertook a long-range plan to create teams that work efficiently, which would create ongoing cost savings, she says.

Under the work transformation plan, the teams are moving toward making 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 devised 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," she explains.

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.

Erasing department lines

The executive team took the ideas submitted by all areas in the hospital and included them in a new organizational chart that eliminated departments and replaced them with divisions, including rehabilitation services, cardiology, medical and behavioral health, surgical, maternal and 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 make it work. The rehab team spent nine months developing the system and inaugurated it in May 1996.

Before reorganization, rehab nursing was part of the hospital’s overall nursing department. There was a rehabilitation department with a director of rehab, a director of physical therapy, a director of occupational therapy, a director of speech and language pathology, and a director of rehabilitation nursing.

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

Clarke’s division includes eight teams: the skilled nursing facility team; 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 therapyclinic teams; and the rehab administration team, which includes Clarke and her secretary. (For more on job descriptions, see story, below.)

"We don’t have a therapy director to set up the schedules," Clarke says. "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."