Evaluate productivity of your whole staff
Measuring team visits rather then individuals
Productivity standards are a necessary evil for home infusion providers. Many providers find it’s more effective to tally the productivity of each home infusion nurse, but only to find an aggregate number of visits per day for nurses. One provider using such a system is the Visiting Nurse Association (VNA) of Greater Philadelphia.
"We measure each individual’s productivity and aggregate that into team productivity," says Stephen Thompson, RN, BA, CRNI, CNSN, director of infusion services division for VNA of Greater Philadelphia. "It is the responsibility of the managers who do the scheduling to have their whole team net out at what our goal is. We shoot for gross productivity of four cases per day."
Gordon Mann, RPh, team leader of home infusion therapy at Elkhart (IN) General Home Care, also is using the team approach to productivity.
"We have standards per visit and per activity and data is collected on an individual basis, but we measure it as a team," he says. "The purpose for that is one nurse might drive a lot of miles to see a patient, and another nurse might drive fewer miles and see lots of patients."
Too many factors influence productivity
Thompson says expecting individuals to meet a daily goal is nearly impossible because of the wide variety of home infusion visits.
"We evaluate the department’s productivity by the aggregate rather than by the individual because there are too many factors that can influence individual productivity, such as the number of miles that have to be driven in order to see your cases, whether it’s a new case or a revisit, and other factors that affect a nurse’s ability to effectively route themselves from one location to another," says Thompson. "Treatments can be time-specific, so they may have to travel in an inefficient fashion to meet the time requirements and care needs of the patients."
VNA of Greater Philadelphia’s home infusion staff is broken into two teams, with seven on one team and eight on the other.
"The teams are divided geographically in respect to our coverage area," says Thompson. "On a yearly basis, we analyze what zip codes our referrals have fallen into to get a sense of caseload volume by geographic location and make up divi ding lines for these particular teams."
Thompson adds that just as important as providing a fair geographic coverage area for a team is matching individuals with the strengths and weaknesses of other members of the team.
"For each specific team, we try to balance off their specific individual skills, so, for instance, you have the same number of chemotherapy-certified nurses on each team," he says.
For Elkhart General Home Care, a total of 35 RNs are broken down into five teams: a north team, a south team, a complex team, an OB/ infant care team, and a home infusion team. Mann’s home infusion team consists of three nurses. Each nurse covers a separate geographic region. Mileage averages 23 miles per visit and has been as high as 200 miles in one day, according to Mann.
Thompson says he looks at productivity numbers once per month. He says reviewing numbers any more frequently is nothing more than micromanaging the natural fluctuations of any business.
"It takes a few months of below-expected productivity before I would make a decision to cut staff, or if productivity numbers were through the ceiling and the numbers told me I was overworking my staff it would take a couple of months to identify a trend," he notes. "This business has ebbs and flows and you have to account for them."
The four-visits-per-day aggregate number of visits per nurse is a result of years of evaluating expectations and intangibles that can effect the duration of a visit.
"It was through a lot of years of trial and error," he says. "Initially we tried to identify different factors and find an average time per visit."
The data are collected using daily route sheets developed in-house. (See productivity chart on p. 5.) Staff turn in daily route sheets that list visit times and what visits were made. The data are then compiled by support staff and turned into aggregate data for each team.
Elkhart’s aggregate is also four visits per day, based on standards of six hours for an admission, two hours for a visit, and a "therapy day" standard (consisting of monitoring patients and preparing supplies) of 15 minutes per therapy day. Mann says new standards of 4.5 hours for an admission and 30 minutes for a delivery are planned to better track actual costs to potentially justify delivery personnel.
"We only look at the aggregate, not at individuals," says Mann of the four-visit-per-day productivity expectation. "We take the total number of admissions, visits, and therapy days and multiply that by the standards and get a total number of hours that should have been worked. We then compare this to the actual payroll for the same time period."
VNA of Greater Philadelphia could simply compile the total number of visits made for each team to come up with an aggregate per-nurse visit number. However, that wouldn’t allow for closer analysis, according to Thompson.
"If we see a quarterly trend that shows decreased productivity on one specific team, through individual productivity analysis you may be able to narrow it down to one particular person," he says. "Then we decide if that person needs some additional training and support. Most of the time it is a matter of retraining and a refocus of the nurse’s energy on the concept of productivity and how important that is to our overall business plan."
Other times a careful analysis of an individual nurse’s caseload will show there is an individual factor causing lower productivity. For example, if a therapy requires the nurse to stay in a home for six hours during a therapy and that patient is on the nurse’s caseload for two or three months, the productivity number would be low, but Thompson would be able to account for the change and write it off.
Like Thompson, Mann collects individual data but looks at them intermittently and waits for several review periods before attributing a change in productivity to a trend rather than a spike or drop.
"We look at it on a pay-period basis, which is every two weeks, but normally I let numbers even out throughout the year," says Mann. "Our nurses are very good at taking vacation time when they don’t have visits, and because we’re part of a larger home health agency, they will do home health visits if we’re low on home infusion visits."
Give a little to staff to get something back
Mann notes that such a system averts micromanagement and allows for the variables in home infusion that can affect an individual’s productivity.
"What it comes down to is, what is the value of your nursing staff?" he says. "My nurses have children and families at home, and they need to work five days a week, eight hours a day to feed their families. I could tell them to take half a day off because we don’t have visits, but I’m less likely to keep quality staff. I’m going to have to give a little to them in order for them to give back to me."
Thompson agrees that looking at aggregate numbers has a great benefit for staff.
"It recognizes the difficulties and individual circumstances they face in their daily job," he says. "Because there are so many factors that can affect productivity, this seems more fair. The staff perceives that and it tends to create a better team environment."