Get the most from staff: 2 paths to productivity
Do you pay professional staff by the visit in an effort to increase their productivity and squeeze more visits into each day? Or do you pay hourly, fearing that quality of care will suffer otherwise?
A pair of home infusion agencies that sit on opposite sides of the fence share their views on the issue. While there is no wrong or right way to pay staff, both agencies present solid arguments for their respective methods of compensating staff. Judge for yourself which agency’s problems most closely resemble your own. By looking at how changing compensation in each of the following case studies alleviated existing problems and increased productivity, you can get a good indication of how you should consider compensating your staff:
• Case Study #1: Pay per visit.
Morale was low and dropping, with productivity tagging along for the ride. Nurses were complaining, but the reasons were inconsistent: Some complained they were too busy; some said they were not busy enough. That’s when Lewis Bowman, RN, quality assurance manager of Serenity Homecare of Utah in Midvale, Utah, knew it was time for a change.
Low staff satisfaction
"There was a lower satisfaction with their job than we had anticipated, so we addressed that," he says. "The productivity and low morale went hand in hand. They did not like that they were on a constant roller coaster ride," says Bowman, referring to the workload that could vary widely from week to week.
Serenity Homecare’s answer to staff morale and productivity problems was to go from hourly to per-visit payment. Bowman took the lead in making the change, which he says was a five-week, three-step process that led to a 10% increase in the agency’s productivity as a whole. The steps were as follows:
Step 1: Bowman took to the field and went on a number of visits himself, carefully tracking the time it took for each visit.
"I spent four weeks in the field doing a really good mix of visits," he says.
Step 2: Taking the information from his field visits, Bowman took a computer printout of the visits made by his staff during the previous three months and compared the length of his own visits to the duration and number of those made by his staff.
Step 3: Finally, Bowman analyzed the information to see where there were possible problems for his staff. Bowman first noticed that staff weren’t necessarily taking too long for each visit. Instead, there was the wide variety of visits and patients each nurse was dealing with.
By looking at his staff’s visits, Bowman felt there was not enough emphasis placed on proper scheduling. There was little, if any, consistency in the staff’s schedule, which led to low morale. Nurses handled a wide variety of patients and had widely varying caseloads from one week to the next.
With staff compensated the same regardless of the number of visits in a week, there was little reason to worry if an individual was occasionally high or low. Now that staff are paid per-visit, it’s important that all staff get the same number of visits per week.
"[Changing to per visit pay] is a tool we are trying to use to even the workload," says Bowman.
At first his staff didn’t buy into it.
"Many were against it," he recalls. "We had a meeting that lasted about 45 minutes, and I told them it wasn’t a tool to whip them into more work but to balance things out so everyone was carrying an even load."
Provide staff questionnaires for feedback
Bowman then provided questionnaires to his staff to solicit input. In hindsight, it was one of the smartest moves he made. It was through a staff suggestion that the final pay-per-visit scale became acuity rated, with more weight being given to the more complex visits.
"We use a very rough acuity system based on our own interpretations and outcomes," he says. "Each staff member is assigned a mix of high- and low-level acuity visits."
Visits are rated on a scale of one through five. A one would be routine care such as a routine lab draw and medication management. A five is a higher level of acuity, such as a post-op patient with intensive IV therapy.
The scale was based on Bowman’s field visits. However, no therapy’s rating is etched in stone, notes Bowman.
"Often times, because I had not seen all of the clientele, I wasn’t aware of what exactly was going on in a scenario," he says.
Nurses sometimes ask him to reconsider the acuity rating for a particular patient, which Bowman says usually arises from the clientele that need "extra psycho-social work."
The scheduling process was at the core of the changes, according to Bowman. Scheduling previously was done on a hit-or-miss basis, with the scheduler assigning visits considering little more than whether a nurse in the vicinity could squeeze in the patient. But no more. Now, the scheduler also considers the skills required for the visit and which nurse would be best suited for the visit.
With greater attention to detail when scheduling staff resulting in more work for the scheduler, Bowman has picked up a portion of the scheduling to avoid paying the scheduler overtime.
Under the new productivity requirements installed in June of this year, full-time RN managers are scheduled for 20-25 visits weekly, including between five and seven supervisory visits. This takes into account not only an even mix of high- and low-level acuity visits but also travel. Each nurse averages 70-100 miles each day.
Annual bonus available
The new productivity requirements also allow for a bonus based on annual performance. The bonus is usually awarded on the employee’s birthday or around Christmas.
To compute the bonus, the agency first compares the performance quote with the individual staff member’s actual numbers. Then, using patient surveys, it takes into consideration the patient satisfaction of the clientele that particular employee is servicing.
"The bonus is then a balance between their performance [production and satisfaction] and what the agency has in its budget based on that year’s profitability.
"It’s quite early in the change, but we’ve seen a 10% [total] increase in productivity," says Bowman. "I attribute that to better time management [both from the scheduler and staff]. The bottom line is before the staff felt they were working for the company, and now they are feeling they’re working with the company."
• Case Study #2: Geographic teams
With the number of daily visits ranging from as high as nine for some nurses to 21¼2 or three for others, Sharon Burkholder, RN, program director at First Care Health Services in Halifax, VA, also was looking to bring consistency to her staff’s workload.
The agency, which serves as the home office for four home care agencies that provide infusion services, previously had both contract and salaried nurses. But the productivity was as varied as their reimbursement.
"If a nurse was [hourly] she would see seven, eight, or nine patients a day, and that was her own choice," says Burkholder. "But we had salaried nurses as low as 21¼2 or three a day, so we’ve really had to put some standards into place and hold the nurses responsible for their productivity level."
While full-time personnel had always been paid hourly, part-time staff were paid by the visit, which created problems. When the agency had a heavy workload, part-time nurses were taking home more than the full-time salaried staff by making eight or nine visits each day.
"The downside of contract reimbursement is nurses see so many people," notes Burkholder. "That was one reason we stopped. We felt like the patients didn’t get full-quality visits, meaning patients would get significantly less time spent with them [during visits], and that’s a problem. Quality can definitely suffer."
With some nurses recording nearly three times as many visits as others, Burkholder didn’t look to reprimand one extreme or the other. Instead, she chose to find a happy medium between quality of care and productivity.
The staff at each office were broken down into teams, each of which was assigned a geographic area. Much like Bowman’s agency, much of the dilemma of nurses meeting their productivity numbers now falls on the shoulder of the scheduler, who must know how long visits should take and the time it should take a nurse to travel from one visit to the next, and schedule visits accordingly.
Scheduler must provide a fair visit mix
Unlike Serenity Homecare, however, First Care does not weight its visits according to acuity. For its productivity purposes, a visit is a visit, regardless of complexity; however, much like Serenity, the scheduler is responsible for providing a fair mix of visits, both in number and acuity level to the staff. Also, the agency uses a weekly rather than daily productivity report, allowing for a nurse to have a long visit one day and one or two shorter visits through the course of the week. Current expectations for staff nurses are 22-25 visits each week.
"I realize all the work that goes along with the visits," says Burkholder. "I was a staff nurse myself, and I think a minimum of 4.5 to five visits a day is a pretty accurate assessment of what our nurses can do."
Travel time was considered when Burkholder established her agencies’ productivity expectation numbers. Her nurses travel about 100 miles each day.
Nurses complete vouchers with time and mileage information for each visit. These vouchers are given to the secretary, who then enters the data into a computer. The data is then compiled into an end-of-week productivity report. Nurses were previously making three or more visits each day, and the number has since increased to 5.5 or six. Burkholder credits the increase to simply establishing a minimum requirement, which was not in place when individuals were averaging three visits a day.
The agency also compiles a monthly productivity sheet, excluding vacation and weekends in figuring productivity. (Some agencies add these hours in as nonvisit related hours).
There has been improved continuity of care since switching to hourly rates, says Burkholder, in part because of better communication among staff.
"It’s impossible for a nurse to see the same patients all the time," she says. Now, staff comes into the central office at the end of each day and, instead of trying to squeeze in one more visit to boost their own pay, they have the time to have conferences and discuss with one another any problems that come up with patients.
Yet, staff is consistently exceeding the productivity expectations. Burkholder says her staff is exceeding the expectation of 4.5 visits a day 90% of the time. Agency procedures state that any nurse who goes an entire quarter (three months) and averages four visits a day or less would be counseled by the director to see if there is a problem. So far, the agency hasn’t had to resort to the measure.
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