Playing for the same team
Playing for the same team
Ramona VNA and Hospice in Hemet, CA, had a typical home care agency structure: Case managers oversee a group of patients and reported to a nurse manager. "But with OASIS, we knew that to meet timeliness and performance improvement requirements, we would have to change things," says Marilyn Stoner, RN, MSN, vice president of the full-service agency. The result was an experiment in teaming staff that she describes as "wildly successful."
Among the benefits: home health aide supervisory visits, which were at 85% or 90% before the change are at 100% now in both the agency’s offices. There has also been a reduction in the number of different staff members seeing each patient, which has had a positive impact on patient satisfaction scores.
Employee satisfaction is also up, says Stoner, and staff members find it easier to talk to a team leader than find time with a manager. "Our office is large, and 12 people can’t talk at once to one manager. It also helps in cases when you introduce some procedural change, like OASIS. Now, we have a larger supply of people who know what has to be done than under the old system of case managers."
Although Stoner hasn’t measured this yet, she also believes that physician satisfaction has improved from the program. "Rather than getting several calls with questions from several different people here, the team leader can make one call and get all the questions answered," she says. And if there is a problem with a particular patient, there is a point person to go to who knows about the case. "Before, if there was a problem, I would get the call. Then I would have to research the issue, talk to various people, and then call the person back."
Finding an equation that works
"We tried a lot of things," Stoner says of her grand experiment. "We looked at different team sizes and whether they should be multidisciplinary or discipline specific. In the end, Ramona VNA opted for the latter, with teams of five to eight people working with about 60 patients.
Beginning late last year, the agency looked for nurses to volunteer as team leaders and create the program from scratch. Those team leaders simply started trying different things in a pilot project with no rules. If they tried a particular sized team and it didn’t work, they changed it. If putting different disciplines together didn’t work because there wasn’t enough work for a social worker on any one group of patients, then that was scrapped. What evolved over two or three months was the teaming program that Ramona VNA has operated for some six months now.
"We had 400 patients in our Hemet office," explains Stoner. "When they knew what they wanted, we changed that office. Then we changed at our Sun City office, then with our intermittent care program, then with our hospice program."
The team leaders are treated and paid as clinical specialists. Indeed, one of the characteristics Stoner looked for in finding her team leaders were her clinical experts. "We also wanted the best documenters — those who had the highest regulatory compliance."
Stoner says she had no difficulty in getting the change accepted by her nurses and other staff. "People were anxious for change."
That’s not to say that there weren’t issues to be resolved. For instance, it was difficult for team leaders to decide where they wanted the lines of authority to stop, Stoner says. "As it is now, they don’t discipline, they don’t hire, they don’t fire. Some agencies might want to include those things. But deciding what kind of job these people want or don’t want is hard." There was also an issue in determining what issues were for the team leader to decide, and which should be brought to the attention of a manager. "It took us a short time to work out. It was an evolutionary process."
Stoner says that there is no reason to make all the changes all at once, that letting things grow can make a project turn out better than you anticipated. Among her other tips for making a team program work:
1.Centralize scheduling. This is a must, she says. "Scheduling is a complex term that needs to be broken down into its components." Team leaders start the process, while the schedulers write out the schedules and answer questions about who is seeing whom. They also manage the per diem staff as much as possible. "This has been an incredibly difficult part of the job."
2.Select a good team size. "We aim for 80 to 100 patients per team," says Stoner. Those patients are managed by five to eight nurses, physical therapists, LVNs (to provide wound care) and occasionally other rehabilitation specialists or social workers. "We have them, but not enough work to assign them to teams."
3.Maintain high productivity. The best way to do this is to facilitate communication, although this remains a challenge between disciplines.
4.Choose your team leaders. Stoner says all those involved in the pilot project volunteered, and all those who volunteered were among the strongest nursing staff at Ramona VNA. "They were enthusiastic to try this system."
Lastly, Stoner thinks everyone should read the book A Simpler Way by Margaret J. Wheatley and Myron Kellner-Rogers (Berret-Koehler Publishing, 1998; list price $19.95). "This should be our bible," says Stoner. The book begins by saying that we all want life to be "less arduous and more playful. We are all just killing ourselves from stress."
Rather than demanding that any change work right the first time and immediately, this book reinforces that "playing" with a theory and letting it evolve is a better way. "Organizations are living things. They evolve like species. If you pay attention to the innovation as it occurs, you get farther faster. That’s what we did with this project."
Stoner says agencies that think their staff need more support to meet regulatory requirements might benefit from this team structure. "We don’t want to baby-sit our staff or make them feel we don’t trust them. But regulations are so complicated now. Team leaders provide a checkpoint for staff."
Source
Marilyn Stoner, RN, MSN, Vice President, Ramona VNA and Hospice, 890 W. Stetson 92543. Telephone: (909) 658-9288.Ave., Hemet, CA
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