HH Administrator Seeking Feedback About Productivity

Once again, I genuinely appreciate the feedback. It's great to hear someone else's perspective. Yes, I agree that communication styles can really morph the intended meaning of a statement so your point is well taken. You had some interesting comments about the loneliness factor. Perhaps that is why they have felt unappreciated. I never considered that. With regards to the staffing model, as previously mentioned-our RNs never drive more than 1 to 2 hr per day- unless they are on call. And a typical day would be 2 -3 visits/day for 4 days of the week and a built in office day once per week. If the nurses need to pick up their children or attend a school function, we have no problem working with them on those things. I'm also a single mother so I understand the need for flexible scheduling. Thanks again!

KatyRN~ the staff definitely know that we offer a flexible scheduling. That part of the office culture has been present prior to my arrival and it's a huge perk. You may be on to something with my communication style. In this forum, I could see where it might come across as being cold, rigid, and formal. That's not my personality at all. Live and in person, I'm warm, fun, and open-minded but always fair and consistent. That's how I perceive myself. (Hopefully, I'm not looking in the funhouse mirror..haha) The nurses actually seem to be comfortable talking to me and their direct supervisor. A couple of the nurses who left actually were the ones who told me that they felt like I was questioning their nursing judgment when I offered to help them look for a reason to recert by doing a chart review. That's how I learned that bit of info. I respect them for telling me. It's not easy to give your boss that kind of feedback. They weren't being mean or catty when they said it. I believe they were being honest. We have a neutral party from another department conduct all of our exit interviews. We also do anonymous exit surveys to try to ascertain even more information.

More on that discharge issue.. Our exec admin really scrutizes our number of discharges so I do reviews to make sure they're goals are met and well documented, that they are truly homebound, etc. And I can totally understand how some nurses could view this as being micro- managed. So I go into great detail to explain that sometimes, a fresh set of eyes can pick out something that they might have overlooked. I had suggested letting them do peer reviews but that idea went over like a lead balloon. lol.

I am directly involved with the QI department so we are always conducting chart reviews on wound care patients, patients who were hospitalized, etc. Our approach is to provide QI feedback to the group as a whole without divulging the patient name or the nurses involved. Occasionally, we will have to meet with a nurse individually and coach her on what was missed, etc. I'll be honest, we've had a bit of a learning curve with some of our nurses both the new ones and the seasoned ones. As we have really revamped our QI department, our nurses are getting more feedback than ever. It's never derogatory or demeaning. I don't believe in that style of leadership. However, some nurses are receptive to feedback and some aren't.

My position as the Administrator is unique in that I'm actually middle management. I have an exec admin team above me and one clinical supervisor below me. I have to tell you~ middle management is tough. But I accepted the position so I accept all that goes along with it. I always make the exec team aware of the staff concerns. Both the clinical supervisor and I are solid advocates for our staff. But we also have to carry out the instructions of the exec admin team and try to meet the goals they establish for us. Sometimes, the goals are negotiable but often they are not. So we work diligently to come up with solutions that are win- win for both.

Perhaps it's the nature of a for-profit organization that is causing unhappiness. Our patients receive the services that they need. The staff members, clinical supervisor, and I are unwavering in that aspect. However, with all of these Medicare changes, we really have to plan ahead and really be smart how we spend their healthcare dollars. I'm not sure of any agency that can send a home health aide out 3 days a week anymore. One of the nurses told me that she didn't really think she should have to worry about any of the financial aspects of patient care. This made me really question if I had failed her in some way by not properly defining the role of a case manager when she was in her orientation phase.

I love the idea of improving the socialization aspect. I'm already thinking of things to do.

I'm not in any way trying to say that my company runs a perfect organization. We wouldn't have had the staff turnover of late. I definitely get that. But so far, I'm hearing the workload isn't completely unreasonable.. and that we seem to fair in what we expect of the nurses in the coordination of care aspect. A communication mishap? Perhaps. I'm doing some soul searching on that one. I've worked for employers who were cold, demeaning, and even derogatory. I sure hope I don't come across that way. It's definitely not my intention. I'm thinking my frustration with the situation is pretty evident. I'm working through that..... it's another reason I'm here....seeking info, suggestions, and tips.

We have a neutral party conduct the exit interviews in order to get the most accurate info so I do believe their opinions that they are working too much are valid to them. I'm struggling with how to make effective changes for a happy medium and still have a financially healthy company. I believe our computer system is a huge part of the problem. We use Misys which is a powerful system. But it takes longer than paper. The IT staff and I have priortized updating Misys and streamlining it to reduce the duplication of documentation. For us, a start of care averages about 3 hrs- maybe more if there are lots of meds to be entered or care to be coordinated. One bit of info we received from the exit interview from one of the RNs was that that a start of care took her about 7 hrs and we expected her to do 2 of them a day. I wasn't sure how to comment to that. Once again, I questioned how I might have failed her in her orientation process. A start of care should not take anyone 7 hrs.

AnnemRN posed the question about whether they are effectively case managing their patients. Some are and some aren't. Our QI department is finding all sorts of things we need to improve upon. And that's OK... I'm tickled we have a QI department. We have office support for them to send faxes, write orders, note orders, make schedule changes. We scan and email the faxes to the RNs so they will be informed. Yet we've still had some incidents where the Case Manager didn't read an email and missed an order. We're all human and that's bound to happen on occasion. Our outcomes need some improvement.

We really manage our type of visits using productivity points. A nurse for our agency should never have 3 starts and a recert. That's way too much. She could have 2 recerts and 2 supervisory (routine) visits. However, that's recently been changed. Our nurses are not suppose to be scheduled more than 6 productivity points per day. A start is 3 points, a recert is 3 points, sup is 1 point, and discharge is 1 point. Our nurses have spaced out their sup visits so they never have more than a couple a day. So they have 6 productivity points for 4 days per week with one office day where they don't see any patients.

I really appreciate the feedback about the discharges. I think I might have offended a couple of nurses by asking questions or by conducting reviews. That was not my intention at all. Whereas I can see how they might feel their judgment was being questions; I'm very careful how I word that conversation because I know how I would feel. I really do view the process as havng another set of eyes looking for something I could have missed. When I was a case manager and I was struggling for a reason to recert, I had no qualms about asking someone to take a look to see if they could find something i'd overlooked. I suppose I assume others are that open. I also realize how all case managers (including me) are prone to manage their own case load when they are understaffed and overwhelmed. I've done it. I've been there so I definitiely understand. My stance has been to really work to be in a proactive staffing position so the RNs don't feel the need to self manage their case load. I've not always gotten approval from my exec admin team. But I've been able to mostly keep the patient load around 30-35. We have a couple of RNs who have occasionally crept up to 40. I try to get a few of their patients reassigned as soon as possible. Ironically, those RNs are still with us.

Another point of dissastifaction is that RNs who resigned really did not like to make visits for other nurses. We really try to make sure this doesn't happen. However, there will always be times when it's unavoidable. They mostly see their own patients though. Vacations, call ins..or even those days when it'sa Friday and the RN has 4 or 5 recerts to be done may result in another RN making some of her visits. It's not optimal...it does interfere with continuity of care but it can not be helped. The built in office day may also cause an RN to have to see someone else's patient so an RN can have that office day. Bottom line is that the office days are dispersed evenly so they all get one...they all take vacations.. and we're all on the same team. We do not employ part time RN case managers at this time. We're not opposed to it. It's sometimes difficult to find that seasoned RN who only wants to do part time and it's really difficult to train a part time nurse to do home health. Thanks again everyone for the feedback. Keep 'em coming. Everyone's comments really force me to think about things from others viewpoint and is very helpful.