New strategy for change in the RT Cave

In my past few posts I emphasized the problem that has caused low morale in this RT Cave, in this post I will state the proposed solution to improving morale.

Yesterday I told my supervisor I was going to quit. I was serious. In fact, as soon as I got home I downloaded an application to another hospital, filled it out, and then went to bed. However, by the time I woke up I had a more level head on. I was ready to tackle the problem head on. The time had come. I had nothing to lose.

At first I thought my bluff wasn't taken seriously. But, when morning came about, and the hour of 4:00 rolled by and I didn't hear from my supervisor, I knew something was amiss.

And, as I was just about to wrap things up for the day, the head RT boss approached me and wanted to see me in his office. Apparently, the supervisor had told him I wanted to quit, and he asked me what the problem was.

"The problem is simple", I told him, "that I have gone home miserable the past few days, and while I had planned on working another 22 years at this place, I refuse to be miserable for 22 years."

"Well," he said, "How can I make it better for you." Wow. Is that all I need to do to get some attention -- threaten to quit. I suppose the squeaky wheel gets the grease. I'm taking advantage of this.

"The answer to that is simple," I said, "Communication. I think that we all seek the same goal of improving the department, but you guys decided you were going to do something and didn't' tell us about it, and then all of a sudden you expect us to be perfect in our charting. That's simply poor business. Thus, I propose, simply that you better communicate."

I could have sat in his office complaining about how poor of a communicator he is, or how stupid the administration at this hospital is, which is what the RT Complainers may do anyway, but I didn't want to stoop to that level. I wanted this meeting to be productive.

"What do you mean by communicate?" he said.

"Exactly like you are doing right now. You are listening to me, and allowing me to speak. And, I am sure, you will explain to me why you are all of a sudden cracking down and expecting us to chart perfectly."

"That makes sense." And he proceeded to explain to me why the crackdown. He explained economic hard times. While the hospital might be really busy today, it has had many slow days. So, when random procedures don't get charted, that amounts to money that is not made for the hospital.

He said, "Okay, any other ideas."

By golly I did. I rattled off a list off the top of my head:

1. I would like a 12 hour leeway in which we can do our charting, or fix any errors in our charting.


2. At the end of the day, I want to be able to print off a sheet that lets us know what we charted, so if we didn't chart something, double charted, or didn't chart something at all we'd be able to see it right then so we could fix it. He thought we had this list already, and I explained we didn't. There, one communication problem fixed.


3. Another co-worker I talked with proposed that instead of leaving notes every day that we made a mistake, that we create a monitoring system where this data is recorded, and at our monthly meeting we can monitor progress or lack there of. If a certain person has more charting errors than the average RT, then he should be set aside and a plan should be worked out to determine how this might be improved. If the department as a whole is making the same errors, then perhaps a new strategy for charting should be implemented.

After I left his office, I coincidentally picked up a book I had in my basement and read it, considering it was only 174 pages long and pertained exactly to the situation at hand in our RT cave. The name of the book was The Effective Executive by Peter Drucker.

In this book he talks about a model for effective executive leadership. It shows a way to turn a failing model around into a successful model. And, considering the new policy in our department that attempted to make us RTs perfect on a dime, and that resulted in excessive complaining, animosity and low morale, this situation was on my mind as I read the book.

According to Newt Gingrich in his new book Real Change, Drucker's strategy goes something like this:

1. What do you VALUE?


2. What VISION of success do you have for achieving what you value?


3. What METRICS would tell you whether you are making progress toward your vision?


4. What STRATEGIES would enable you to achieve your vision?


5. What PROJECTS would enable you to implement your strategies successfully?


6. What TASKS have to be done well to complete each project?

Before I left his office I cracked a joke to lighten up the atmosphere, and then I told him I felt better now that we communicated, and I thought it would be a good idea to communicate like this with the rest of the staff as well. I was impressed when one of my co-workers called me to inform me she was to have a meeting with the boss later in the day, as has every other RT in the Cave.

"What the heck did you tell him," she said.

"Everything," I said, "What did I have to lose."

We value more communication and good morale in our department. We want back what was stolen from us when this new policy was enacted. Our vision of success is involving the entire department in the decision making.

Jane Sage is the one who thought of a strategy for metrics, and this is her idea was to create a monitoring system that showed us what we were doing wrong and whether it was the entire department or if some of us were more more prone to making mistakes than others, and what exactly were the mistakes.

Metrics is more than just the statistics that are pounded on us at each department meeting, statistics that show ups and downs in the monthly financial status, or how well the hospital is perceived within the community, or the RT department for that matter (as a side note, we are viewed as excellent on a regular basis).

While the statistics can show some trends, statistics cannot show morale. Likewise, statistics can become stale. Thus, having good metrics is a far better means of solving a problem.

By my meeting with the head RT boss I listed some of my ideas for improving the problem. And, as he plans on talking with other RTs, they will list some of their strategies, projects and tasks, and then we will get together in our next departmental meeting an analyze all the information accumulated and try to implement a plan.

Newt Gingrich, in his book Real Change writes that "Albert Einstein had a firm rule for thinking about new solutions. He asserted the following: thinking that doing more of the same will lead to a different outcome is a sign of insanity (Emphasis added).

Thus, even before any of us had read any book on the subject, we were on the right track.

Thus it only makes sense for the RT bosses to implement a new strategy to achieve their goal. This meeting I had with the boss was only the first step, I'll keep you guys updated on how things progress from here.

Tension in the RT Cave

What I wrote in my previous post, "New policy enacted to make RTs perfect," was my facetious interpretation of some of the rules the administration has laid down on us RTs in an attempt to improve our charting.

Personally, I think the RT bosses and the administration are well intentioned in their attempt at making us better at charting. Here, allow me to highlight two very important reasons why RT bosses might require their RTs to clamp down and at least try to do a better job of charting.

First one must realize the following:

1) All of our charting is now electronic, and billing is automatically done when we hit file. For example, if an RT does CPT, and forgets to click on CPT when he does his charting, then that is one procedure that is not billed for. Even though this doesn't happen on a regular basis, it still happens. According to the RT bosses, even these little mistakes have amounted to $30,000 in un-billed procedures over the past billing period alone. Especially in these hard economic times, these little errors can be very costly.

2) If an RT is called to court, accurate and complete charting can be of a major benefit to the hospital. We had an instance lately at Shoreline where a case went to court mainly because one nurse did shoddy charting. However, the RTs did excellent charting, and this resulted in the case getting thrown out. (I will write about this later.)

So, these two situations amounted to the administration clamping down on this particular RT department. They simply want us to pay more attention to our charting.

However, the major problem with this was not the general idea, but the way it was communicated to us by our RT boss. The general feeling among us RTs was that the bosses no longer cared about patient care so long as we charted accurately. I must add that this was not true, it's simply how it came across.

I understood the animosity of the department, I listened to the complainers, and even found myself complaining myself. After all, I am not perfect. In my opinion, perfection is a flaw in itself.

However, when I was left a note last week that I forgot to pull a file on an EKG, and my supervisor told me this was "unacceptable." I came back with the following line in my humble attempt to explain to her that perfection is not possible.

"Say, for example," I said, "We RTs do 100 procedures, and our charting is perfect on 99 of those 100. That's a 99% rate of success. Do you consider that unacceptable."

"Yes," she said, "I do."

"99% is unacceptable."

"Absolutely."

"Well, then, what can I say. I guess you'll have to fire us all, because we are all going to make mistakes from time to time."

In a rare occurrence, I found myself arguing with my boss. It's not that I tried to fight with her, I was merely trying to explain to her why the animosity; why the low morale.

Later, in discussing this with my good friend and fellow RT Jane Sage, she explained it this way:

"I have worked here for 20 years," she said, "and for 19-and-a-half of those years no one ever said anything about my charting being unacceptable. Now, all of a sudden my charting is unacceptable. So, what that tells me, is that I was unacceptable for all of those 20 years and no one told me. I've always been an awefull charter, and no one said a word."

Hell, I've even heard complaining from RTs who never complain, so obviously there was something wrong here. So when I approached my supervisor again to inform her of the problem, and that some RTs were already talking about quitting if the RT Boss starting writing RTs up for not being perfect.

As I was approaching her for the third time on this matter, she emphatically told me I was being ridiculous. "This all wouldn't be a problem if our billing wasn't dropped right from our charting. As with many hospitals, we have had some financial bla bla bla bla...

So, in rare form, I told her I was going to quit.

New policy enacted to make RTs perfect

Shoreline is not run by JCAHO as most hospitals are, but ISO. If you think JCAHO is incompetent and out of touch with reality, consider this new policy ISO pretty much forced the administration to put pressure on the RT bosses to crack down on random errors. The ultimate goal here is to make RTs perfect:

---

Date: April 28, 2007
To: RT Staff
From: RT bosses
Regarding: New Departmental Policy

To prevent any further wasting of our time trying to deal with pesky RTs and all their demands, we RT bosses have created the following list for the further good of our medical institution:

1. An RT supervisor will be assigned the responsibility of double checking every single treatment and order to make sure all the i's are dotted and t's are crossed. If there is any mistake, a note will be given.


2. No matter what the note is for, after every seven notes the RT will get a write up.


3. All incentive spirometer instructs must be completed within an hour of the order or there will be a note given to the RT notifying him or her of the error. We demand thorough documentation as to why the IS was not done. Failure to document appropriately will result in a note


4. EKGs, ABGs, Holter monitors, incentive spirometers, treatments are all equal priority therapies and must be completed in a timely manner regardless of how busy the RT is. If any of these are not completed in a timely manner, a note will be left for the RT.


5. A SOB patient does not take priority over a patient who is not SOB. The excuse that such and such patient needed my services at that time more than the patient who has been here for three months and is still on treatments will no longer work at this facility. If an RT complains this is ridiculous, the RT will be called an idiot and sent home for the rest of the day. He will also be given a note.


6. All EKGs must be done within 10 minutes of the original page. There will be no allowable excuses such as, "I was busy with a SOB patient," or, "I was at a code."


7. All Q4 hour treatments must be done exactly every 4 hours. There will be no exceptions. If a Q4 treatment is done at 8:15, the next treatment should be done at exactly 12:15. We will no longer allow a 30 minute leeway on Q4. We will allow a leeway of 10 minutes and no more.


8. All Q6 hour treatments must be done exactly every 6 hours. We will allow no more than a 30 minute leeway. Q6 hour treatments done 20 minutes late will result in a note.


9. We will no longer tolerate complaints that therapy is not indicated. If the doctor ordered it, it is needed. Period.


10. Regarding #11, this includes Q2 hour breathing treatments on a patient who is not having bronchospasm and is in no respiratory distress. If the doctor ordered it, then it must be done exactly as ordered.


11. If you can't get a treatment done when it is due, you must not ever chart "unable to do," even if this may truly be the reason. It does not matter if you had a code. It does not matter that you had a pt. who was laboring. If a treatment was due, and you truly can't get to it, you must call in help.


12. You must call in help if unable to do a treatment even if the treatment is not indicated, and even though we know it takes most help 45 minutes to arrive and the treatment must be completed no later than 30 minutes late. When charts are reviewed the following day, a note will be left if the treatment is more than 30 minutes late.


13. Call in help will not receive time and a half for coming in and helping unless the RT is over the 40 hour mark, even if they would be going above and beyond the call of duty by coming in and helping out the business.


14. All overtime pay must be pre-approved. It doesn't matter if it is on a weekend or late at night, it must be pre-approved regardless of the reason.


15. RT Bosses are not to be called after 5 p.m. or on weekends.


16. If a patient is SOB or appears to have the look of impending doom, your responsibility as an RT is to stay with that patient until he is stabilized. This only makes sense.


17. There will be no excuses for late therapies. Late therapies will result in a note.


18. Q4PRN treatments must be assessed and charted every four hours. If you forget to chart why treatment not given, you will receive a note.


19. For every seven notes, you will receive a written warning.


20. All notes have the same priority, whether they were because you forgot to chart a med or whether you forgot to chart that a prn treatment was not given.


21. If you complain about notes you will be given a note.


22. If you complain that you are burned out because of all the new demands set for you, you will be told that you have forgotten how to work and then you will be ignored for your stupid comment.


23. If you go over the RT bosses head to complain about stupid useless treatments, you will be ignored.


24. If you go over the RT bosses head to complain about all the stupid notes, you will be ignored.


25. If you go over the RT bosses head to complain that all your notes were for silly things like forgetting to chart PRN treatments and it's stupid that you now have a write up, you will be laughed and mocked because we expect perfection.


26. If you get home and remember you forgot to chart something, too bad: that note with your name on it is already on the bulletin board.

---

As you might have guessed, this new policy has created quite a bit of animosity in our department. When I got wind of this policy a few months ago I warned the RT bosses this would back-fire on them, and I was right.

I'll let you guys consider the above, and then I'll discuss this in more detail in the coming days. In the mean time, I have a question for my fellow RTs: are your RT bosses cracking down like this, or is it just here at Shoreline?

New Vent protocol biproduct of teamwork

There has been a lot of discussion lately on the blogosphere about how hospitals may be more efficient if there was a more cohesive effort on the part of administrators in involving employees in the process of decision making.

I imagine our hospital is no different in this regards as compared with any other hospital, however we do provide one prime example of what good can come from more than one group of individuals coming together and making decisions to the benefit of all parties involved.

I've written before on this blog about the advantages of the Keystone committee and it's efforts to reduce the incidence of VAP while at the same time saving the hospital millions of dollars per year on wasted medical costs. It's main effort has been by getting administrators, doctors, nurses and respiratory therapists together to figure out a solution.

At Shoreline, the resulting decision was called a ventilator protocol. However, in retrospect, this protocol wasn't really a ventilator protocol, but a ventilator weaning protocol. However, since the protocol has been enacted, the number of days on a ventilator has been chopped by a large margin, and the incidence of VAP has been nearly evaporated.

To further improve the statistics, the doctor in charge of Shoreline's Keystone Committee approached my friend Jane Sage, the RT on the committee, about improving the ventilator protocol. She said that not only did she want it to be a weaning protocol, but she wanted to change the protocol so that RTs could change the rate and tidal volumes based on EtCO2 readings.

Likewise, instead of drawing ABGs every morning and with every vent change, we would now be able to make vent changes without doing the invasive ABG draw, but simply by monitoring the SpO2 and the EtCO2.

These new changes are yet to be approved, but this is a major revelation for an RT department that was protocol depleted as of just two years ago. When Mrs. Sage told me about this doctor approaching her with this new information, I wanted to run out of the hospital and pump my arm into the air shouting ululations like, "Woooo Hoooo."

This, I think, is a quintessential example of what good results can come about when many great minds are put together, as opposed to the administration and doctors getting all the privilege of decision making.

You decide: Landscaping or overtime pay???

We had a discussion recently in the blogosphere about how much better run hospitals would be, and happier the workers like you and me would be, if there was more co-ordination between the administration and hospital employees.

I thought of this as I drove my wife to work this morning, and noticed a bunch of landscaping trucks parked out back. In my opinion, there is already enough money invested in landscaping so the property looks 310% better than any landscaping in my sub-division, so I can't imagine what more would really, truly need to be done.

It reminded me of our last department meeting, when we learned that the hospital was going to be spending millions of dollars funding and redesigning the hospital image, creating a new sign, logo and color scheme for the hospital. Yet, moments later, we learned that the hospital was in a financial crunch, and there would be a lock down on all overtime and on call pay.

A perfect example of this was last Sunday when my boss scolded me because I was swamped on Saturday night and wrote "no lunch" on my time card. What this would amount to was the department paying me time-and-a-half for one half of an hour for me basically doing the work of two people all night long.

In talking with the good folks back in OB, they are no longer allowed to have a person on call. So, when they are in a crunch, when every second is of importance, the nurses will have to get on the phone and start calling every single employee of that department right down the line on the list.

The thing is, since whomever comes in will not get overtime pay unless that person is already over 40 hours for the week, who would want to come in. I sure wouldn't. However, out of due respect for your friends whom are currently in a jam, someone usually bites the bullet and comes in to help.

Quite frankly, I've been known to do the same thing in my department when my co-workers are in a jam. I come in to help even though my company is too cheap, and too short on money, to pay me the well deserved time-and-a-half-pay I should get for being nice, for sacrificing my quality family time.

Yet, while the hospital is busy being cheap with us, it continues to fork out millions of dollars on beautifying the hospital grounds. It would seem to me that there would be a better way of managing the "few" dollars that the hospital has.

There is an answer, and it is to have one or two of us employees sitting on the board so we can put in our two cents worth. So we can make sure the hospital is taking care of us, and not simply its image.