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.

This 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. 121.)

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 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.

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 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.

Creating efficiency

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 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.

No rehab jobs were lost

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 a 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 with the number before the reorganization, Clarke says.

For instance, in the past, staff from departments such environmental services, distribution, admissions, and food and nutrition worked in rehabilitation 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 departments have lost employees.

Staff improve their skills

The number of licensed staff has remained the same, Clarke adds. Because the unlicensed staff are now cross-trained, the skill level of the staff has increased, she says. In addition to staff in nursing and therapy, all staff who work on the unit are assigned to specific teams. Some positions are combinations of previous jobs. (For more information on the new job descriptions at Memorial Hospital, see story, p. 119.)

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

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

"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 skilled nursing facility unit, the neuro-ortho surgical nursing unit, and inpatient rehabilitation.

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 place these therapists in two groups: those who work primarily in the outpatient setting and those who work primarily in the acute care 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, she says.

Providing coverage

"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 it wasn’t so easy under the current organizational plan, she 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.]