RT bosses, admins think on different level as RTs

I can kind of understand why the administration here at Shoreline has been having conniption fits lately, and why they have been clamping down on on us lately, as I come to work today to learn there is an entire patient floor closed due to lack of patients.

As I wrote in a previous post, the size of this hospital is too small to be considered a large hospital, and too large to be considered a small hospital. As we are too small, we don't make enough money to be able to have extra staff on hand, which should explain to you why I have to work alone on nights regardless of whether I have eight patients on my board, or 22.

We are too large to receive government grants. Which is funny, because when I used to work at Death Line Medical Center, which is about 40 miles from Shorline Medical, I never could figure out how they could afford to have two therapists during the day. The RTs there never got called off, even if there was no work. When I worked there I was told, "If you are scheduled, why would the place call you off?"

Well, here at Shoreline, when it's slow, people get called off work. So how could these two hospitals so close together have such a different view on when to call workers off? I'll tell you the answer, Shoreline is located in such the perfect (or imperfect) location where we have just enough more patients than Death Line that we are over the line that would classify us as a small hospital. And, since we are over that line, we do not qualify for government grants.

So I suppose when the patient load is down, like it is today, workers get called off. The surgical floor and the step-down unit have both been closed, and, of course, all the staff that usually works over there are getting called off. While over at Death Line, even though their census is down too, well, they continue to make their paychecks.

That's just the way the medical field is. In September and October, if you remember from my posts, we were so slow for so long I wondered if it would ever pick up. Then from November through May we were so busy all the staff here was getting burned out. Now the cycle has come full circle, and we are excessively slow again.

So, I can see why the administration would make a big deal about a few miss charted treatments. If we were busy all the time like some big city hospitals, then I don't think the administration would have the time to worry about the minor things. If we were small, and the hospital received extra money from the government to cover its debt as is the case with Death Line, I don't think it would matter either.

But, since Shoreline is not small and not big, the administration spends that extra time looking at all the statistics. They get bored and instead of taking care of more important matters, they sit around double checking all our charting to make sure we dotted all the i's and crossed all the t's. The get nit-picky. And sometimes they make decisions that they see as for the better of the institution, yet they forget to involve us in the process.

And that, my friends, is why some RT departments might develop a low morale from time to time. The admins don't intend for morale to dip, but it just does. It does because the staff feels like the admins are making a big deal out of spilled milk. And, quite frankly, they are making a big deal out of spilled milk. But, as more and more smaller hospitals are merging, or closing their doors, Shoreline has managed to stay afloat -- alone. So, perhaps, this little nit-pickiness is a necessry component of independence.

Now, whether this battle to maintain as an independent hospital works to the advantage to us RTs or not I have no clue. Part of me thinks it would be bad. But, the other part of me thinks that if we merged with Aero Medical Center, that we would all get nice hefty raises so our staff would be paid as well as their staff. As, being a smaller hospital (not small enough, not big enough), the administration here will not even consider the idea of giving us all hefty raises.

But why would they give us raises? All the RTs in this department have been here so long we are all complacent. We have worked here so long, have so many friends here, love it here so much, are comfortable here, that we wouldn't go anywhere else to work. In a way, that's true. I am comfortable here. I love it here. I have many friends here. I'm complacent. And, while I could go somewhere else, I don't. It's far easier to stay here. Besides, if I decided to take another job, at Death Line for example, I'd have to drive. That's wear and tear on my car, and, hell, with gas prices at near $4.00 a gallon, I'm better off staying here, where my drive is only five minutes.

And, with 10 RTs here, and all of us in relatively the same boat as me, the administration can afford to push us a little bit. And this, what I write today, is some of the mentality behind the administration forcing our RT bosses to crack down on our charting, making a big deal of little errors, and make an attempt, as my fellow RTs and I like to put it, to make us perfect.

While I do have a bachelor's degree in business, and an associates in respiratory therapy, I still don't know as much about hospital administration as some of you guys. If I am ever to move up the ladder and become one of them, there is a lot I have to learn. However, I would imagine that my analysis here is not too far from reality.

Usually here at Shoreline the morale is high. Usually, all we little RTs and RT bosses and administrators get along. Some of us get along in close little friendship type relationships, and some of us in good little business relationships. Some of us, like me, have a combo of the two. But on occasion the administration pushes our buttons just because they can. And slowly but surely the morale will decline. The morale will decline until someone gets tired of it all and mossies on into the RT bosses headquarters for a little chit chat.

Then, once the RT bosses realize that they pushed us a little too far, they back off. Then morale starts to climb. Then things get back to normal for a year or so until someone in the administration gets another idea, and the RT bosses, or the administration itself, pushes us over that line again. They will wait just long enough so they think we forgot the last time they tried to cross the line. But we are smarter that: we don't forget.

I've worked here long enough now to know this is how it goes at a hospital that's too big to be small and too small to be big. That's just how it goes.

Tonight I came to work with a self diagnosed acute exacerbation of chronic laziness. I feel this way not just because I had too many days off, but because the patient census is so low again. Now, I'm not making a big deal about this, because I love it when its slow because I get paid to blog, as I'm doing now. And perhaps I blog too much, but you guys can be the judge of that. But the downside of a low census, as I've already explained, is that the admins get all stressed out. And when the admins get all stressed out, so too will the RT bosses. That's just how it goes.

This time around, it was my turn to let the RT bosses know they went too far. I had my little chit chat with the head RT boss. I had to tell him that morale was down. That it was so bad that even people in ER were asking me about the "tension" in the RT Cave.

"What?" he said. "I didn't know tension was that bad?"

Well, guess what? There ain't no tension anymore. While the RT bosses still want to improve our charting, improve the little things, they have backed off. It's like clockwork. I know these guys like the back of my hand.

Sometimes, as I sit here thinking about it, I think I could do that job and better than those guys. I think if I were the RT boss, there would be no lack of communication, particularly because I've worked here on nights for 10 years and I know what it's like to be on this end and I'd have empathy.

Then again, both RT bosses were RTs once upon a time. They are both dragons now.

Then again, I think that once I cross over and become an RT boss, I will slowly but surely turn into one of them. I will slowly turn into a dragon. I will slowly forget about simple RT mindset, and start thinking in terms of money. For RT bosses, money is the bottom line. And money can do a lot of damage to ones mind. Hell, just look at Hollywood for some good examples of that. RT bosses aren't' far removed from that crowd. They get a little wacky sometimes. They don't think rationally. I'd like to think I'd be different if I were an RT boss, but would I?? Who knows.

Now, getting back to the size of this hospital. Death Line has remodeled all its rooms so that all patients now get a private room. They have remodeled all the OB rooms so there is a hot tub in all the rooms -- and they are all private too. And they have a brand new ER. I've decided they get to do all that because of the government grants, which they get because they are just a little less busy than us and are qualified by the Fed as a small hospital.

Here at Shoreline, well, we are stuck with an ER that is just too small, especially in the summer when all the visitors flush into the region, and an OB that is way too old for modern times, and patient rooms that are too small for all the modern equipment and two patients per room.

Yet, even while we have this old facility, the admins have managed to keep it looking pretty sharp. While we have an old ER, we have a damn good staff. While we have an old, rickety OB, we pride ourselves in knowing we have a far better staff than Death Line. We take care of our patients as good as the best big hospital, the best small hospital, and the best hospital that is too large to be small and too small to be large.

And, for the most part, except for a few bumps in the road, the morale is high here. We are all one big happy family. All the units work well together, and I know it's not like that at all hospitals, as I've worked for some where there was no click between departments. And since we all know oneanother on a personal basis, because this IS still a small town no matter how the Fed wants to define Shoreline.

So, while the admins at this too big to be small and too small to be big hospital can sometimes get a little anal about little things, things that would be totally ignored in other hospitals, they still do a pretty damn good at keeping this place together.

Hell, all they would have to do is go down into the basement and look at the main computer to see that I've been blogging here all night, and they could make a big deal about it -- but they won't. They won't because I hold this RT Cave up while they are away. I make this place look good (except for my little piddly mistakes).

And besides, because I'm complacent here, because I have kids in the local schools I'm trapped in a way in this small town of Shoreline. I come to work every day not just because I want to, not just because I'm a great RT, but because I have to. I have to because the alternative would mean moving my kids to a new school again, and I don't want to do that.

The admins know this. They know this because this is how it is for about 80% of the people who work here. Because of this, and because they know I love the aura here at Shoreline, an aura the admins helped to create in those many periods of high morale, they know they can get me for a cheap wage. The funny thing is I know this, and yet I'm still here. I know their game. I'm just smart enough to know their game.

So they won't say a word to me any more about this little game they have been playing about being perfect. Because, as I told the head RT boss the other day when I approached him in a civil manner, "I do not have to stay here. None of us have to work here. We work here because we love it here, but we do not have to stay here. So let's move on."

And we will. For the next two or three years the admins will not try to push us over that line. And they better not, because I could just as easily go over to Death Line and work for a better looking yet inferior institution.

Then again, they might call my bluff.

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:

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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.

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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?