Establishing reasonable expectations for staff
Establishing reasonable expectations for staff
Is your agency flirting with disaster?
As evidenced in the Rite Aid pharmacy case, a jury may not look favorably on an agency that tries to squeeze employees dry to increase productivity. The jury placed the blame on Rite Aid and the assigned workload of its on-site pharmacists for a pharmacist’s error that resulted in severe brain damage in a 7-year old. The child’s family received $16 million. (See story, p. 79.) But how can you tell what’s too much work for your own staff?
"From my perspective, the issue of appropriate productivity is a question that remains very much open," says Elizabeth Hogue, JD, a health care attorney in Burtonsville, MD.
Hogue says standards regarding numbers of visits are sorely missing from home care. She’s seen agencies in which staff make only three or four visits each day and others in which staff claim nearly 20 a day. What’s the right balance?
"Understand that when we talk about home care and productivity, it’s not like we have some huge database on which to base our conclusions," Hogue says. "Management just looks at three or four visits a day and says, We’ve got to be more productive, so now we’re going to say staff members have to do five or six visits a day.’"
The decision to increase productivity rather than hire additional staff has long been a tactic in business. But business and health care sometimes mix as well as oil and water.
"To do more with less, to cut profits and increase productivity, is a very basic business strategy," says Louise Nelson, CRNI, and a senior staff nurse for Apria Healthcare Group’s Beltsville, MD, home care office. "Translating it to health care delivery creates a few bumps in the road. You may be able to redesign a manufacturing process to increase productivity, but when you’re talking about human beings taking care of human beings, there’s a limit."
Mark Kadzielski, JD, head of the West Coast health practice for Epstein Becker & Green, a law firm in Los Angeles, says many agencies may be unknowingly putting themselves at legal risk. He suggests you consider the following two points when considering your own productivity quotas:
1. Use the reasonableness standard.
A court of law, Kadzielski says, would use the reasonableness standard to evaluate your agency’s quotas. You’ll need to judge for yourself how reasonable the expectations are that you’ve established for your staff. Because there’s no baseline test, such as "six visits a day is fine, but seven visits is expecting too much," you’ll have to do some research.
James C. Anders, JD, a trial lawyer with James C. Anders, PA, a law firm in Columbia, SC, and the plaintiff’s lead attorney in the Rite Aid case, advises providers to seek advice from experts in the industry. Simply compare your agency’s visit quota to other similar agencies.
You can start your research without leaving the confines of your office. Experts interviewed by Home Infusion Therapy Management make the following recommendations on starting your internal evaluation:
• Look to your past.
Hogue says one way to tell if your expectations are too high is to look at your agency’s history. If you’ve recently switched from one method of compensating nurses to another, any dramatic shift in the number of visits should put up a red flag. For example, if you’ve switched from paying staff per visit, and the number of visits has gone through the roof, it’s safe to assume your previous quota was too low.
However, such an escalation in the number of visits could introduce a new problem.
"We’ve seen instances where workers have performed 18 or 19 visits in a day, and we just don’t believe it, unless they’re seeing patients in the middle of the night," says Hogue. "In that case, you might want to establish a cap on the number of visits that they can do to avoid the temptation to run the bill up."
• Analyze paperwork.
Hogue also suggests studying staff documentation to see if there are any signs of cutting corners to squeeze in extra visits.
For example, if a nurse’s documentation shows a visit lasting from 10 a.m. to 11 a.m., a second visit beginning half an hour later at 11:30 a.m., and the nurse had to drive 45 miles between visits, something is wrong.
"Look at the driving time between those visits," Hogue suggests. "You just can’t drive 45 miles in 30 minutes."
Not only will closely monitoring staff documentation show where any corners are being cut, it also can alert you if a nurse records one-hour visits that last only 30-45 minutes or even worse were never made.
"The last thing any agency wants is to find out an employee really didn’t make visits and then have to try and figure out what they should do vis a vis the intermediary," says Hogue. "On one hand, you might not want to volunteer anything, but on the other hand, you’ve been paid for claims you now know are false."
False visits aren’t the only problems. Even less significant methods of cutting corners could surface later and place your agency in an unfavorable light.
"In the Olympics, we’ve gotten to where hundredths of a second is a new world record," Nelson says. "I hope we’re not moving in that direction in health care where a 25-minute visit is better than a 30-minute visit."
But to meet quotas, some staff may do just that.
"I’ve had patients say You’re taking my vital signs; everybody doesn’t do that,’ and that has to be reported back to management because that is part of our normal visit," says Nelson. "If the patient says it hasn’t always been done, but vital signs have been written down on all of the visit records, somebody’s got to look into it."
• Keep your ear to the ground.
Not every staff complaint about workload is a sign of trouble. However, complaints sometimes do signal a problem, Nelson says, particularly if quotas are in place and expected to be strictly followed.
"My feeling is that people should realize that a quota should be an average and not a Holy Grail and have realistic expectations for the field staff," says Nelson, whose agency has a 4.2 visits-per-day quota established by Apria’s home office in Costa Mesa, CA. "In my particular branch, our managers are very sensible. If you can justify that a visit took longer than average, that’s fine most of the time. Productivity should not vary so much from nurse to nurse but instead from patient to patient."
By not providing leeway, you’re setting your agency up for a poor working environment, something Nelson has seen firsthand at other agencies.
"Some nurses feel harassed when they’re called in, sat down, and asked why they’re over the standard," says Nelson. "So they lie about their time and work off the clock because they feel so much pressure from management that they’re not productive enough."
How would a jury view your agency in light of such testimony?
• Take off the blinders.
Once you’re satisfied with your internal processes, Kadzielski recommends thoroughly comparing your agency to others. But make sure you’re comparing apples to apples.
"Prudent advice is to look at others in the industry and see how reasonable it is to expect somebody to see X number of patients a day," he says. "Remember, if you’re in a geographic area of 30 city blocks, maybe you can see that many clients in a day. But if you’re in a geographic area of 300 square miles, that number won’t make a whole lot of sense. You need to get data on what other similar institutions are doing so there is some kind of standardization."
2. Don’t wait until it’s too late.
Kadzielski says the above tips may seem nothing more than common sense, but that’s no reason not to evaluate staff-visit quotas carefully.
"Do they want to have to wait for a jury verdict to find out if what they’ve done is inappropriate?" he asks.
There’s no shortage of professionals who argue that quality of care has suffered as profits have taken a front seat. Don’t let your agency become an example of that.
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