Tips for the good RT Boss

The following is a guest post from Will Lessons, retired RRT

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I worked with Bob for 16 years.  He was a fun guy, and we would spend hours on slow days tossing EKG stickers at the clock or seeing how far our spit would drop from the stairwell. I mean, you have to be fun to do something like this.  Then we'd go out to the nurses station at 4 am and flirt with the female nurses.  On our days off we also had fun together.  

I also remember when it was really busy once Bob and I were taking care of a critical patient.  We so happened to rush into the supply room at the same time, and we realized there was no oxygen tubing.  Bob said, "Watch this!" as he ripped open a venturi mask and took out the oxygen tubing.  "Now we have oxygen tubing."

A few years later Bob became an RT boss and he completely forgot what it was like to be an RT.  It was like he completely morphed from a peasant to a dragon.  Instead of having fun with us he put a stop to all fun.  He was still nice, but he was meticulous at enforcing the rules set forth by the administrators.  He morphed from all fun to all no fun.  Everyone hated him.  He was great at managing the department, but his communication skills dropped off the southern end of the map.

So when he moved on and I became the RT Boss, I decided I wanted to be everything Bob was and everything Bob was not.  During my interview I said to the admins questioning me:  "Bob was a great boss.  He did many great things for this department.  I want to continue all he did.  Where Bob failed was he was a poor communicator.  He made decisions and forced them on us, or at least it appeared that way.  When someone approached him he did all the talking.  The result was a low morale.  I think we would all be better off if we all felt like we were a part of the process.  That's the best way to get the best results, at the best cost, and the lowest amount of waste."  

And then I added, "At least that's what I think.  And I understand you may not hire me because I'm being truthful here, but I think this is important in a boss.  This is from my observation."  

I was hired.  And I kept my door open at all times.  And I kept my voice off.  The sign on my door read:  "Come in and be heard."  That's my advice for prospective and current RT bosses.  Work among the staff, not above them.  

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Thanks once again Will.

Two ways to hire doctors: Part 2

The following is a guest post from Will Lessons, retired RRT:

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Last week I wrote about the two ways of hiring doctors.  Basically you have large hospitals that have a large pool of doctors to choose from, and they get to pick the best of the crop.  Small town hospitals don't have a large crop, and they pretty much get the leftovers.

 Many small towns, therefore, tend to hire any doctor that is available, and this sometimes results in doctors that otherwise never would have been hired.  This often results in doctors who are power control doctors who want things done their way or the high way.  

They tend to frown upon respiratory therapists as ancillary staff who do what they are told.  This often results in RTs who have low morale and a bad working relationship with these physicians.  Now there are exceptions to the rule, yet for the most part this is my observation. 

Again, I must say that most doctors are awesome, yet the 10% of doctors who are generally your rejects tend to work for your small town hospitals.  That's just how it is.  And, again, this is my speculation.  

So that's the problem.  Now what can be done about it?  It's almost a no brainer here.  I think the best way to remedy this dilemma is for hospitals to hold doctors to the same standards as when hiring any of their other staff.  Doctors should take the same personality test.  Doctors should be asked the same questions.  Whomever is doing the hiring must make sure the doctors hired fit the personality of the hospital.  

A second thing I think would help is to involve other people in the hiring process.  If you're hiring a urologist, ask the other urologist to participate in the interview process.  If it's an ER doctor, ask your nurses or doctors or respiratory therapists their past experiences with this doctor.  Often you can get a feel for how a doctor will fit in by simply talking with the people who already work for you.

Surely there's no way to fool proof the hiring process.  You can have the best interview, and it may seem you're hiring the best person for the job, and still you you could hire a buffoon.  I've seen it happen by the best of interviewers.  When I was Supervisor for an RT department once I hired a couple people on the same day who looked to be very fine RTs, and they both flopped.  Yet on the other side, I hired one against my better judgment and on a recommendation from a fellow RT, and this person turned into an elite RTs.  

So perfection is not possible.  Yet still you could come up with a technique whereby you can pick out most of the weeds.  

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Thanks again Will.

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Things RT bosses can do to keep you happy

Studies have overwhelmingly showed that the more satisfied workers are the more satisfied their customers will be.  This provides bosses with an added incentive to keep workers happy.

That in mind, here are some ways your boss may try to keep you happy:

• Parties
• Birthday cards
• Bonuses
• Good benefits
• Annual raises
• Involving you in tasks (writing protocols, teaching nurses, teaching BLS, writing policy, etc.)
• Involve you in departmental decision making
• Creating protocols
• Listening to you
• Giving praise

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Reversing a Bullying Culture

A dire situation is looming in the U.S. healthcare system. It has been noted that respiratory therapy dissatisfaction and related intent to leave the work environment and being powerless to do anything about it are believed to be key factors contributing to a significant increase in RT dry humor and a significant increase in RT complainers.

Moreover, exposure to incivility, including workplace bullying, particularly by RT Bosses, and lack of turnover, is one of the primary factors influencing RT dissatisfaction, and can be a reason why some leave the the profession altogether, or yearn to do so.

Evidence suggests workplace bullying by RT Bosses and related disruptive behavior are commonplace, and on the rise. The combination of a busy healthcare setting, difficult patient situations, and the requirement for interdependent relationships can serve as a breeding ground for incivility and bullying behaviors.

In response to a survey by the Joint Commission, more than 75% of RTs reported having been a victim of bullying and/or disruptive behavior by RT bosses at work, and more than 90% stated that they witnessed the abusive behavior of others.

Despite the subsequent Joint Commission Sentinel Alert requiring healthcare facilities to design and implement a system wide approach to ensure employee awareness of disruptive and/or bullying behaviors, bullying continues and still is perceived to be steadily on the rise.

The implications for RT's work environments are noteworthy, since the health and availability of RTs are vital for the provision of a safe environment for our most vulnerable population -- the patients we serve.

At the core of incivility and bullying seems to be, according to most RTs surveyed, complaint due to stupid doctor orders, or doctors who simply have no clue what the purpose of a bronchodilator
is.

"When we talk to our bosses about questionable therapies, they simply blow us off," wrote one of the surveyed RTs. "The comment we get most often is: 'we need these procedures so you can keep your jobs, so we hate to start cornering doctors and holding them accountable for their stupid orders."

Of the 75% of dissatisfied RTs, studies show 80% of them develop a keen sense of humor, as noted over at the Respiratory Therapy Cave and again over at Respiratory Therapy 101.

Dr. Ven T. Olin, president of the National Physician's Association of America noted that "all this extra humor in the hospitals has created an aura of lack of respect for physicians and RT Bosses by RTs, but thankfully no RT Bosses have the nerve to cross the physicians ordering stupid procedures for fear of losing procedure counts.

In a letter to this author, Mr. Olin noted, "if our RTs don't chart their procedures correctly, we expect RT Bosses to hound them until they become perfect. It's not something we want to do, but we have to do it."

So, instead of crossing the physicians, RT Bosses often cross the irritated RTs, and sometimes even become irate to the point of shouting. RT Bosses have been known to force RTs to be perfect, or suffer through humiliating notes that make them aware of all their flaws.

"Yes," Mr. Olin notes, "It happens at hospitals across the nation. It has been the beaming topic of RT blogs across the nation."

According to the joint commission, a committee is currently performing an extensive review in response to concerned RTs, and is currently looking for additional information about effective approaches to address these challenges.

KUDOS TO THE ADMINS

I have to give kudos where kudos are due. I have to give kudos to the ER boss and the nurses of the ER for listening to and incorporating the advice of this and other RTs.

As I have written on this blog before, it was getting to the point that EKGs were ordered for such frivolous orders, or the patient wasn't available when the RT dropped what he was doing and rushed to ER, that many of us RTs stopped rushing to do EKGs in the ER.

It got to the point our EKG response time was really bad, like 20 minutes. That's not good, especially when you have a patient who is having life threatening chest pain -- or an MI (a heart attack). In these situations, an EKG should be done within 10 minutes from the time the patient entered the door.

ACLS also recommends such EKGs be done within 10 minutes. Yet, still, there were so many stupid EKG orders that we RTs stopped rushing down. I suppose they desensitized us to the word STAT.

Now, I recommended to my RT Boss that ER should call us stat for ACLS EKGs, and ASAP for all others. That way we can prioritize, and if we can't get down right away we can call and the ER staff can do the EKG. My boss said, "There is no reason you should ever not get down to ER right away to do an EKG."

That ended the discussion. A while later I talked to the ER Boss, and she liked my idea. But, five years later, nothing ever changed.

Now, however, my idea is implemented and going well. The door to EKG time has improved from 20 minutes three months ago to 8 minutes. That's great.

In fact, yesterday one of the nurses pointed me to a sign on the window that notified us of this great improvement, and the nurse said, "Kudos to you."

I said, "No! Kudos to you and your boss."

I meant that. Now that the ER staf page us RTs STAT for procedures that should be done STAT, we know that when we get paged STAT it means STAT.

Of course it took money for the change to finally be implemented. Six months ago the head RN boss noticed that insurance companies will pay for any EKG on patients over 29 complaining of atraumatic chest pain. She also noticed that they weren't paying for most of our EKGs because the door to EKG times were way too often greater than 10 minutes.

So, she got one member from each department together at a meeting to determine what could be done to speed up the time from door to EKGs.

I was picked by the RT boss to represent the RT Cave. My suggestion was simple: "Call us STAT only for ACLC EKGs. In other words, call us STAT for Atraumatic Chest Pains."

The idea was implemented. And, no surprise, it works. We RTs are happy because we know exactly when we need to rush, the nurses are happy because they no longer have to complain we took too long, and the RT Bosses are happy because they get paid."

So, kudo's to the bosses at Shoreline Medical Center. You've earned it.

Respect garners respect, yet they don't know it

We RTs at the RT cave were told by the head RT boss that we don't take our jobs seriously enough. We make too many needless mistakes in our charting. We complain too often about stupid doctor orders. We make up fake diagnoses that better explain why the patient is really in the hospital, such as exaggeration of asthma.

Yet, at the same time, during a meetings a year ago one of my co-workers brought up the fact that one particular doctor in the ER "doesn't know what the #$#@# she is doing. She orders treatments every hour until discharge on CHF patients, and does Q30 minute Xopenex treatments for croup."

So, as a group, we wanted this doctor investigated. We wanted it documented that she orders more procedures than any other doctor.

The next meeting the results were it: This particular doctor in question did not order more treatments than any other doctor.

However, this study did not take into consideration that the doctor in question works nights, where fewer patients are admitted. Yet, based on the results, the RT bosses dropped the issue.

Recently the issue was brought up again. In fact, this time we kept a stack of dumb doctor orders by this doctor. The RT Boss looked at that stack and said, "Look, we need these procedures to keep our jobs. With the economy the way it is, you should just be happy to be working."

I discussed this with another of my co-workers, who said this: "How can they expect us to take our jobs seriously when they don't take us seriously."

Point made.

Here's a great con to Nationalized Healthcare

Here is one very good reason I am against a nationalized health care system. I discussed with my boss yesterday about the budget. He said his bosses want him to come up with "everything and anything" ideas for further cutting the budget.

He asked me, "Any ideas."

I said, "Create a treatment protocol so we can get rid of all the breathing treatments that are not needed. That would save us a ton of money." (To learn how much money this would actually save our hospital, click here.)

He said, "Rick, you should be happy just to have a job. We need all the procedures right now we can get."

Here's something to consider. The hospital does not get paid by the government per procedure completed, it gets one flat rate for the patent's stay. So, the fewer procedures done while the patient is admitted the more money the hospital would make.

Thus, if Shoreline Medical Center could come up with a protocol to prevent doctors from giving an asthma/COPD medicine just because a patient is short of breath or sounds bad or looks funny (or to prevent bronchodilator abuse), that would save the hospital hundreds of thousands of dollars a year.

What I understand here is that when it comes to cutting the hospital's budget my boss only thinks in terms of his own wallet, while ignoring the wallet of everyone else. What he fails to understand (what many people seem to misunderstand these days) is the government's wallet is OUR money too.

My boss is afraid if we get a protocol, the number of procedures in our department will go down, and someone will lose his or her job. It seems to me many hospital bosses would prefer the procedure than to prevent government waste.

Yes government reform is needed, but not in the direction the current House, Senate and Executive Branch visions. The change we need is to provide an incentive for hospital admins to spend the government's money as wisely as it spends it's own.

As the old saying goes: people are more likely to spend their own money wisely, yet when it comes to spending someone else's money, they appear to be less wise (or is that a saying I just made up). Anyway, it's true.

Feel free to discuss because, as always, I could be mistaken.

(Other than the links above, for more of my opinion on Nationalized Healthcare, click here.)

Is profit now more important than saving lives??

Most respiratory therapists are pretty good at what they do. We aren't just chums and peons who slap a neb in someone's mouth and leave the room, we assess and we do creative thinking to the benefit of the patient.

But many doctors and nurses and Rt bosses and administrators don't understand that. They see us as ancillary staff, no better than the technician that draws your blood or performs an ordinary x-ray.

Very few times in the 13 years I've been in this profession have I heard of one of my coworkers making a mistake that endangered the life of one of the patients. In fact, I can think of no examples of which this happened. In fact, perhaps it never has.

Yet we have all spent time in the RT Bosses office from time to time defending ourselves because of some write up for some stupid reason, or, most common, because we forgot to chart a treatment.

It's almost to the point now that I spend so much time worrying that I'm charting correctly, and charting all my therapies, that charting has become the priority, with patients taking a distant second place. The number one goal of hospitals is not to save lives and make sick people better, it's to make money.

My coworker told me that she told the boss several years ago if it ever got to the point she was paranoid that she was going to make a mistake for creative thinking that she would quit. Now that's exactly what it's come to here at Shoreline Medical Center. We have all become paranoid.

We're not paranoid because we think we are going to compromise our patients, because they always come first to us. We are paranoid because we are afraid we aren't going to chart perfectly. We are told if we don't chart all our stuff we (meaning the department) won't get paid for a procedure.

Now I certainly want the department to make money, as I want to make a paycheck, but I think it's bull crap now that it's to the point we are all paranoid.

It makes one think this way:

"Which is more important: Doing something to harm a patient or forgetting to chart a treatment?"

I like to think, as do most ethical human beings, that the first goal is to do no harm. Yet now I'm beginning to wonder if the greater priority is making sure we chart so we can make the hospital profitable.

It's a shame I have to write about this, but it's true.

How to create a successful business (RT Cave)

In the past few days I wrote one post on how to make a better Rt Cave as far as morale and productivity (click here), and one post to show the reason why morale is often low in RT caves across the country (click here).

Today I came across another post similar to mine (better actually) over at RespiratoryTherapy101. He wrote about the techniques used by Scott Adams to run a successful business. They are:

1. Have fun. Loosen up.
2. Try something new. Often. Keep whatever works.
3. No penalty for a new idea failing. Trying is the thing.
4. Employees are more important than customers.
5. Stop asking Scott for approval. Just do it.
6. Managers get to see the financials.
7. Being a jerk to coworkers is grounds for termination.
8. Do whatever seems smart and fair to make customers happy.
9. Watch the competition closely and borrow their best ideas.

Like the anonymous RT over at RT 101, I love #4.

One of my coworkers argues with me that the customer is always right. She even puts her patients so far ahead of herself that she often goes nights without eating.

I said to her, "That's stupid. If you don't eat, if you don't sleep good, if you don't take care of yourself, you are eventually not going to be taking good care of your customer. You need to take care of yourself so you can take good care of your customer -- the patient."

Likewise, RT bosses and administration needs to provide good incentives, good benefits, fair wages, respect, and open ears to the people working for them.

As the anonymous RT writes, "...employees need to feel valued and respected to be productive."

I too wish Mr. Adams would come and talk with the bosses and adminstration up here at Shoreline Medical Center. We all would benefit.

If I were the boss of the RT Cave...

I've been thinking lately how I would run an RT department if I had the opportunity (not that I would want that job.)

The first thing I would do is anything possible to create a mileau where RTs will want to work for this department. Not only will you be challenged, you will be encouraged to participate. You have an idea, come forward! You will not be ignored.

There are many different ways bosses can run their companies, and the one I would choose is the one that involves the worker in every step of the decision process. That way morale stays high because all the workers know they are a part of everthing the department represents.

You see, my goal in life is to be happy. I believe nothing is really complicated, although some people tend to make things complicated. I would not be one of those people.

Surely we'll have rules and guidelines and policies, yet I'd also leave room for individual thought; some leaway; some freedom to move or (for lack of a better word)... to breathe.

We RTs become humbled

When he got his job as an RT he had so many ideas to make it better. Yet when he came forward with his ideas he was screamed at and scolded by the RT Boss. Still he marched forward with new ideas, and each time he continued to be scolded.

Sometimes his ideas were approved. Once he asked for a new airway box, and the boss approved that idea. So, four years later when we still had the OLD airway box, he just figured the boss had lied -- In year #5 we actually got the box. Yep, it took five years.

Sometimes I'd listen on as he'd keep his mouth shut and listen to the lecture of why we as an RT department can't do this or that. I wondered why the boss didn't just tell him his ideas were great but he would have to go through the system the way he did with the airway box.

Of course any person who "goes through the system" (otherwise known as a bureaucracy) knows it can be extremely frustrating and extremely long. My friend once said to me, "If we were simply allowed to solve problems as they arose instead of going through the system, there would be no problem in the first place. It might even up morale."

And other times he'd make a gallant attempt to explain his position. And once or twice this resorted into a shouting match. And, of course, these little fights were always the fault of the person coming up with the new ideas, and not the RT Boss.

Perhaps he could have approached the boss in another way. But, instead of approaching the boss again, he came up with new ideas and has them stacked in a pile in his locker doing no one any good, except once in a while when he brings one of those papers to a meeting. And, hence, the bosses usually say, "That sounds like a great idea," and cast it aside.

So all the geniuses in our department were quashed. The one I'm referring to in this post nearly quit once or twice, but staying here is a lot more "convenient" than traveling two hours to the other hospital. He also decided the grass isn't always greener on the other side of the fence. Plus, other than this issue, he loves his job at Shoreline.

"It's frustrating when you have so many solutions yet nobody wants to hear them." He paused, then added, "When they do listen to an idea (a rarity), it's no longer your idea -- it's the admin's idea."

I haven't heard much from the one I'm referring to here in a long while. He has been totally shut up. One like him will never come about again -- too bad.

That is what I thought until recently, when we had a new hire who went through the same process. Recently he came to me and said, "I have come up with some great ideas, and what's the point."

She had many new ideas as new RTs often do. They have many ideas of new products or new RT wisdoms they picked up in RT school. Or something was done a better way at another hospital she worked for.

Yesterday she came to me and told me she was screamed at and scolded so many times that she has decided she will no longer go to the bosses with his ideas.

As he's saying this, I think to myself, "Hmmmmm, sounds familiar." I said to him, "Don't give up, because some day your hard work will pay off."

And so we become humbled as so many before us, yet we never give up.

Quote of the day

"We are expected to spend so much time dotting all our i's and crossing all our t's that we hardly have any time left for old fashioned common sense." me

Make of that what you want.

Rules must be enforced with common sense

Some people take things in stride & prefer to use their individual freedom to solve problems. Some people are tense and have so many rules that in order to keep them happy you have to follow all the rules.

I think some rules are important, but too many rules merely take away individual freedom. And, absent individual freedom, new innovations are stifled. In my humble opinion, this merely stifles creativity.

One of my co-workers took what I thought was a great idea and to the bosses, who promptly heralded it and then brushed it under the carpet. Five years later the promised changes have still not been made.

In essence, my co-workers, tired of being ignored eventually decided to keep their mouths shut and "grin and bear" the status quo. The result here is a bunch of happy workers with no one willing to stand up to fix problem areas. Hence, you either hear grumbling in the RT Cave or, in my case, facetious RT Cave humor.

I hear this a lot: "Why should I go out of my way to share my ideas to make the department better when all I get is ridicule or ignored?"

My co-workers, and myself included, and perhaps even you, are written up when we make serious errors. Of course even the gravest errors are learning experiences, assuming we don't repeat them. Those are acceptable write ups.

Major write-ups are rare. Yet pidly write-ups seem to be a common feature here in the RT Cave. And that, my friends, is one of the problems of working for a small town hospital. Most bigger hospitals have bigger fish to fry, so creating rules for paltry things is not a priority.

One of the best parts of working nights is the freedom of working by myself and prioritizing therapies. Still, the powers that be that set and enforce the rules can make life very stressful for you when they come in and tell you all the "minor" rules you broke, like forgetting to chart, "No treatment indicated" for a prn order.

I say this knowing my greatest priority is not giving treatments that aren't' needed, but saving lives. But, when it comes to the bosses of small town RT caves, they have little else to think about than the things that the larger hospitals WOULD brush under the carpet and not worry about.

That is exactly why large hospitals have protocols that allow us RTs to decide who needs our therapy and who doesn't. Smaller hospitals need the money from all those frivolous therapies to stay in business.

So, the whiny RT says, "Hey, boss, that treatment isn't needed. That patient has never had a bronchospasm in his life."

The boss says, "Whiney, if the doctor ordered it, it's needed."

Hence, whiny finds solace complaining about the "stupid rule," as opposed to making an effort to change it. Still, in my opinion, it's better to be humble. Take your lickin' and keep on tickin.

Whether you like the beast of politics or not, it shows its ugly head around every corner. So you might as well just grin and bear it. Even if it's rules that take away our individual freedoms.

So, I suppose you wonder what my point is. I simply think bosses should think about the rules they make, and have a little leeway in how they enforce the piddly ones like, "Did I dot all the i's and cross all the t's."

Or, said another way: they should encourage a little common sense.

I say this because I'm certainly not going to rush upstairs to do the seven treatments that are due on people who have never had a bronchospasm in their lives, when I have a patient who really does need me in the ER.

But that's common sense.

It is true that absent rules people are lazy. Yet rules must be enforced with some common sense. And that, my friends, is the thought of the day.

Note: The leading hospitals in the world did not get where they are today by stifling creativity.

I'm just enjoying the slow season

Last year at this time we had such a low census that we ended up closing one of the floors. It got so bad that the administration almost went into a panic.

This year the same thing has happened. Our census is low, and the admins are in a panic. They are even talking about laying people off.

"Oh, we might never get busy again," I hear at the meetings.

It happens every year. They say the same thing. They get scared, and they try to make us scared. And then, lo and behold, as the winter months come upon us, the business comes.

And then we are busy until the end of the summer vacation season.

So, I refuse to buy into the panic.

Actually, being the lone RT who works nights, I have never been called off. And, considering no one wants to work nights, I don't have to worry.

The RT department is almost exempt from the lay off fears because there are only 10 of us. Still, on occasion, when the census is down to 4-5 patients on treatments, one of the day RTs has to take a day off and use up his vacation pay.

Of course if the census is really low and no RT wants to lose all his time, we sometimes do 8 hour shifts instead of 12.

Still, the day shifters hate working after 9 p.m., so I usually only miss out on the first 2 hours of my shift if anything. And that's fine by me, because then I get to stay home long enough to tuck in my kids.

So, right now we are stuck in the Q#@^t time of the year. Note, I did not say the Q-word. I certainly don't want to jinx myself.

I certainly don't mind the low census because on nights I can do this. But the day RTs don't get to play on the Internet (ha ha).

We do have our rushes. I mean, after all, this is a hospital and people do have mishaps, and people still do code, and people still do have cp and the occasional SOB episode.

But we simply aren't getting a lot of these people admitted right now. Which, if you think of it, is good for them, good for me, and bad for the admins -- hence the boo-hooing.

And the admins hate the low census. Boo hoo, we aren't making money on all the useless breathing treatments.

I suppose some day I might be an admin and I'll be boo-hooing.

Until them, I'm enjoying it.

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.

Actually, the best way of improving morale is to have happy employees. If you have happy employees, everything else simply falls into place.

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 to obtaining better communication and, perhaps, better morale.

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?