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In the MTV television show Pimp My Ride, rapper and car enthusiast Xzibit takes cars in poor condition to a custom auto body shop, where they restore and personalize the cars to owner tastes. I thought of this show when I put together this month's column on the productivity tool my department uses daily to reconcile the two organizational productivity indices because, boy, has it been "pimped out" since I first shared it in a column three months ago. (See "Recalculating: A Respiratory Department's Journey to 100 Percent Productivity")
The original tool included workload metrics: relative value units, fixed and productivity hours targets, fixed and productive actual hours, fixed in-service, orientation, meetings hours, fixed leadership hours. These metrics generated the two organizational productivity indices, flex and performance. The list of customizations that the department's charge therapists, managers, and I have made since then is extensive. And each played a part in helping my department make significant improvement in flex productivity. As of August 1, the flex index was 81 percent. On Dec. 3, the flex index was 92 percent. The flex index for December was 102 percent.
The staff suggested five "pimped features" that we manually add each day:
1. Relative value units (raw number) change: the difference over the last two days
2. RVU percent change daily: the difference of last two days/previous day RVUs
3. Missed respiratory care handheld nebulizer treatments (safety metrics): This number is pulled from staff Meditech documentation.
4. Flex hours variance: This column shows target minus actual clinical staff flex hours.
5. Productive index hours variance: This column shows target minus actual productive hours. It includes all hours clinical coverage, leadership, in-service and orientation.
The old tool's flex index tracked only the ratio of flexible target clinical staff hours to flexible actual clinical staff hours. The new flex hours variance column gives us this information in hours form so that we can take action to keep our department at its productivity goal. With this new tool, we discovered that on days when the flex index is greater than 100 percent, there will be "banked flex hours" we can use to add additional staff when the workload goes up. We typically add those hours during treatment rounds, but we also may use them to flex down less on weekends when leadership is "on call" not onsite. This column also helped us realized that weekends typically had less scheduled workload drivers, such as cardiothoracic cases, c sections, and road trips to the cath lab.
We also added two columns to track daily work load changes: RVUs compared daily (raw number) and percentage change RVU. We call these the "tsunami" columns because they're an indicator of workload drivers like cardiothoracic surgery cases, c-sections, emergencies, pediatric floors treatment load, road trips to the cath lab, CT or MRI scans on ventilator patients, ER patient volumes, and which ER MDs are scheduled. Here's a tip: Know the trends for these respiratory-care workload tsunami drivers. If 50 percent of these variables are trending up, "surf's up." As in, you'll be using all your banked flex hours. Also, know the overall hospital census. When it is high, especially in the ER and ICU, the likelihood that the department will be on "tsunami" watch is greater. This column also helps our nursing teammates with hourly bed assignments.
The pimped productivity tool also includes a new patient safety column, added to show missed hand-held nebulizer (HHN) treatments. The daily productivity report review, is ready at 1300 the following day, a great improvement over our old monthly productivity report. We're looking to improve upon that: One of our managers is testing a grid that predicts staff hours at 500 RVU ranges and could forecast when we should flex up or down.
Because of these pimped features, we also have convinced administration to change staff and leadership productivity expectations for 2012 so that we're only responsible for what we have influence over: the flex index (goal: 97 percent) and the productivity index (goal: 100 percent), respectively. (Thank you to our VP/CNE for supporting us in this area.) We've also expanded the organization's incentive pay program so that critical staff pay is awarded on weekdays for extra shifts if RVUs are 7,000 or greater, not just on weekends.
Of course, as with any custom build, we made mistakes and learned along the way. First and foremost, we learned that the team leaders and charge therapist for each shift - including weekends - must be included in training so they can help plan for staffing. We initially tried not using the productivity tool to calculate low census on weekends because there is no leadership onsite to provide clinical back up if things get busy. But by the end of the month, we got too far behind on our productivity goals. (Weekends accounted for 26 to 28 percent of a month's hours.) Now, we do a weekend staffing huddle with the charge RCP and leader on call on Friday and recalculate the goal by one or two flex hours.
My department is trying to convert our current shift assignment process to a RVU-based tool so it uses the same measures as the productivity tool, giving us a more accurate way to schedule staff. And in 2012, we're taking a more proactive approach to deciding which staff to send home due to low census. When we develop the six-week schedule, one person is designated as the "call-off" employee for each day. This helps to ensure that we fairly distribute call-offs to employees so they can don't have to take multiple vacation days during the same pay period.
So what should you do if you're trying to pimp your department's productivity tool?
Make the case for change. It is the leader's role to explain to staff why using a productivity tool and calling off employees during low census is necessary. Leadership is stewardship, it is temporary and we are accountable.
Practice transparency. Be honest with staff and admit your mistakes. This is a learning process and their questions will help you to learn and generate new ideas.
Be patient. Remind yourself (often) not to take criticism and staff frustrations personally.
Listen. It is critical to hear and acknowledge staff frustrations, both personal and work-related. They are often intrinsic needs that must be met. Encourage staff to share their frustrations in order to develop a team mentality.
Give away control whenever possible! Set a goal and get out of your staff's way. They will reach it. Then, talk them up to the vice president or chief nursing officer. Fight to get the tool improved.
Start a dialogue. Most of the pimped features were born from a different idea but matured into current feature after staff discussion.
Deal with frustration. Acknowledge that nothing is easy about achieving 100 percent productivity with a "tsunami" workload. There are times when you simply need to stop talking about it. It should not become a distraction to patient safety. This is a "tight rope" experience you have to keep patients safe, but make money to not just survive but thrive. Paying for hospital improvements, attracting
and retaining great staff, and having "state of the art equipment" is critical.
Divvy up clinical work between leaders. My supervisors and I share weekday clinical support and rotate weekend call. I learn so much about the frustrations staff experience when I do this and become more invested in fixing problems.
Just like how the Pimp My Ride auto body shop team runs into problems pimping old car, there are many frustrations in pimping a department's productivity tool. The cure is simple for this Ole Stethoscope leader: keep listening to your teammates and then listen your heart. Because, wow: once again my dream team has exceeded my expectations.
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