Designing jobs correctly is key to decentralization

Lack of leadership can foil efforts

It’s a myth that decentralization is more expensive, says Patricia Garcia Sullivan, RN, vice president of re-engineering initiatives at Mount Sinai Medical Center in New York City.

The key to decentralizing efficiently, she says, is correctly structuring and packaging the jobs involved. Not giving enough thought to constructing the new jobs may result in a lot of variability in activity, Sullivan suggests.

Because the job doesn’t have enough flexibility, employees find themselves overwhelmed at times and with nothing to do on other occasions, she adds. "You need a critical mass of things for these people to do to make it viable."

Health care organizations that fail to decentralize their services might look at these other potential reasons, Sullivan says:

• The organization was tremendously efficient to begin with.

• The organization didn’t fully conceptualize the process and take advantage of technology and process redesign.

• There was a lack of real leadership.

"Many times, what I’ve seen in re-engineering initiatives that fail is that [the organization] falls back into silos," says Sullivan. "There must be some sponsor at the executive level who doesn’t have a vested interest in the outcome."

At Mount Sinai, the majority of managers and directors of areas affected by re-engineering reported to the chief operating officer, she points out. "Other organizations may put the oversight at too low a level, and that doesn’t work. You can’t give [the project] to the vice president of nursing to run."

Decision tree’ aids process

When Mount Sinai started its full-scale re-engineering effort in 1993, the hospital created three or four clinical teams to lead the project, later pulling off some members to form a business team, Sullivan says. That team oversaw admitting and other business functions.

The idea of decentralization was put through a "decision tree" to determine the best place to locate services, she adds. "This forces you to describe a service in detail, to answer questions about processes and subprocesses." Looking at admitting, for example, the team asked:

What are the capital and equipment needs? They are relatively low and include such items as admitting software and equipment to make patient ID plates, telephones, etc.

How long does it take someone to learn the procedures? The team determined it would take someone about four to six weeks to become competent, but not an expert, in admitting skills.

How many admissions does one have to do on an ongoing basis to stay competent? The team decided someone could stay up to speed on admitting skills by doing at least one admission per day.

Are certain functions concentrated in particular patient groups? This is not true of admitting because it is spread across the hospital. With a function such as phlebotomy, however, there would be more concentration in some patient groups than others.

After answering "yes" to the question of whether the hospital could afford to replicate the admitting service based on equipment needs, the team moved down to some other questions:

Does the ability to do this function in more local units improve performance indicators? "With admitting, that’s a definite yes,’" Sullivan notes. "If [an account] needs follow-up, [the business associate] is right there."

Is volume high enough to ensure at least one person in the care center is competent? "If the answer to that is yes,’ keep going," she says. "It could be that you have a small care center with 10 admissions a week, or two a day. That could keep one person competent but maybe not two. Maybe you want a specialist in admitting that works for one unit."

In a big care center, Sullivan adds, there might be five or six business associates, with at least 25 admissions needed to keep those employees competent. "There may be a specialist who only does admitting, or multiskilled people who do admitting and other things, but each person must do at least one admission a day," she explains.

After going through the decision process, the team decided that admitting could be "multiskilled" at most care centers, Sullivan notes.

Another question to be addressed is whether a task is deferrable, she says, meaning that it can be delayed as long as it is done within one day. "If you multiskill a lot of tasks, you have to be careful that they’re not all nondeferrable. You don’t want people batch-entering all the admissions at the end of the day, so that’s a nondeferrable activity."

Although Mount Sinai went with a multiskilled business associate, what has developed, Sullivan says, is an employee who is "less truly multiskilled and more semispecialist."

"It definitely evolves," she adds. "There is a natural tendency to pull back more centrally, but what we’ve succeeded in is keeping [admitting] care center-based and care center-specific. You end up with personnel with different strengths and weaknesses."

In another change, while the hospital first went with one job description for business associates, after two years the position was split into "business associate A" and "business associate B," she says. "The lower-level position reflects those who don’t do admitting, which some employ ees don’t have the desire or capability to do."

She points out, however, that the hospital traded some flexibility for the cost efficiency it gained by not having to pay all associates a higher wage. With fewer of the associates able to do admitting, scheduling becomes harder, she says.

"In general, the admitting process is one of the big satisfiers for patients," Sullivan adds. "It’s about relationships and being able to get more concrete information."

And there’s one more measure of success: The re-engineered Mount Sinai recently received the highest rating in its history — 97 — from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations.

[Editor’s note: Patricia Garcia Sullivan may be reached at (212) 241-6581 or by e-mail at psullivan@]