Clinical decisions handled at the point of service

Management’s role is to support staff

At Memorial Hospital, the clinical decision making process is being shifted from management to the staff who perform hands-on patient care.

"We are trying to get away from the autocratic model, the idea that management tells the staff what to do. Our belief is that people want to do the right thing and that the staff providing the care are best equipped to make decisions," says Karen Clarke, RN, MSN, rehab division manager at the Gulfport, MS, hospital.

Although she emphasizes that shifting decision making to the staff level is an ongoing process that will evolve over time, Clarke says the new staff model is working just a year after its inception.

Here are some of the tasks that normally would be undertaken by management level staff that have been handled by the clinical staff:

• When the rehab division was preparing for an accreditation survey by CARF... The Rehabilitation Commission, the staff took the CARF standards, studied them, and decided what the division should do to get ready for the survey, Clarke says. Under the old system, management would have taken the lead in accreditation preparation, with help from the staff.

• When budget time rolled around, the rehab division had to apportion budgets for 12 departments into budgets for eight teams. Clarke gave the individual teams responsibility for formulating their budgets and working with the other teams to make the figures mesh. "They submitted a budget to me. I ran the figures and found they were right on the money," she says.

• The original staffing patterns were based on an anticipated census of 14. When the census increased, the staff suggested adding a physical therapy assistant and a certified occupational therapy assistant. Clarke agreed.

Here’s how the chain of command works: As division manager, Clarke is responsible for every person on all eight teams in her division.

There are four facilitators to whom she has delegated management responsibility. However, the facilitators are staff-level positions, not line management.

"We identified two areas of staff: point-of- service providers and systems support. All of the staff who do actual hands-on work are point-of-service providers. The facilitators and I are systems support," Clarke says.

At Memorial, the eight teams in the rehabilitation division make their own decisions. "We have transdisciplinary teams where everybody is on equal footing and everybody brings something special to the table," she says.

However, the new lean administration that eliminated the traditional departments left the therapists "treading water on their own" when it came to matters like staffing and practice issues, Clarke says.

Resource coordination

"We did not want to go back to discipline- specific but we needed someone to coordinate resources and handle some of the issues the traditional department managers handled," she explains.

The hospital’s solution was to create the position of facilitator, a staff member with delegated management responsibilities. If a team has questions about how to handle an issue, it goes to the facilitator.

"We have not perfected this system. It is going to be evolving. I still get involved in how we should handle things. I see the teams as being in the developmental stage and needing as much support as possible," Clarke says.

When the inpatient rehab patient-focused care model was instituted in June 1996, there was only one facilitator. She was the resource person for therapy, nursing, and all team issues.

Over time, three other facilitators have been added to handle the workload.

Clarke compares the facilitators’ jobs to those of air traffic controllers. They handle day-to- day operations issues, such as coverage, hiring temporary staff, and working with the acute, outpatient, and inpatient teams on evaluations.

Facilitators also get the therapists back together as a discipline to discuss discipline- specific practice issues such as standards of care.

As facilitator for the inpatient rehab team, Deborah Woods, RN, MSN, CCM, coordinates outcomes management and the team’s partner groups, which meet regularly to discuss clinical, program, and operations issues. The partner groups have tackled issues such as the budget, setting up a program evaluation system, and how to meet accreditation standards.

Woods also coordinates the peer review process. (For more information on peer review, see story, at right.)

The facilitator positions are intended to be support service positions, but in reality, they spend part of their time doing clinical hands-on work, Clarke says.

"My job and the facilitator’s job is to support the team. Our hope is that as we develop and refine our organization, the teams will become self-directed," Clarke says.