Patient-centered care to promote efficiency
New model eliminates layers of administration
Instead of waiting for managed care to heavily penetrate its market, Bryn Mawr Rehab took a proactive stance and redesigned its service delivery system while the hospital was still operating effectively and efficiently.
Managed care had been moving into the marketplace for several years when the Malvern, PA, rehab provider decided to act.
We recognized that what had led us to be successful in the past would not necessarily be the formula for future success," says Jan Bergen, vice president of administration for the hospital.
Before the redesign project that was completed in July 1996, Bryn Mawr had a matrix organizational structure with traditional clinical service departments. Although there were separate programs that served a specific diagnostic population, all staff reported through the traditional departments.
"The matrix is a costly structure, and while it was effective at the time, we determined that our own bureaucracy burdened our costs and limited our ability to really focus on and respond to our patient’s needs, the common needs," Bergen says.
The goal of the re-engineering project was to organize patient care around the patient, rather than around hospital departments and services and their roles, Keating says.
Bryn Mawr’s new model has centralized administrative work and attempts to provide more clinical time for staff, says Daniel Keating, PhD, administrative director for the 141-bed hospital’s neurocognitive division.
The new structure has eliminated the discipline directors and various layers within the disciplines, such as clinical program coordinators and senior therapists.
Under the new design, there are 10 treatment teams responsible for 10 to 12 patients each and made up of everyone on the staff who interacts with the patients. (For an example of how teams are staffed, see chart, p. 22.)
Layers eliminated
Each of the 10 treatment teams is headed by a team coordinator, a clinician who spends approximately half of his or her time in supervisory duties and half in clinical duties. Under the old system, department heads’ duties were generally 80% administrative and 20% clinical.
In the past, therapists had been assigned to programs, but those programs were treated by diagnosis and were not assigned to a specific group of patients. For instance, depending on the schedule, as many as five different physical therapists on the stroke program might treat a particular patient. Staffing decisions for each team were made by each discipline’s department.
The goal of the redesign was that the team of professionals working with patients would make decisions about the allocation of resources, Keating says.
Bryn Mawr’s teams were structured to include nursing and some support staff on all three shifts, as well as the therapy disciplines, psychology, and case management.
"We felt that if we did not integrate nursing into the team, the patients would not receive the benefit of having all disciplines working together for a common goal," Bergen says.
The most distinctive part of the change is that people are oriented by teams, instead of by discipline. For instance, nurses no longer have a traditional reporting mechanism to a nurse manager, says Helen Cioschi, MSN, CRNP, CRRN, administrative director of the ortho-medical section, Cioschi says.
Rethinking roles
"Staff have had to rethink the role of manager in a more generalized way. It’s not a discipline focus, it is a rehab specialty focus. For some people that is a difficult transition, Cioschi says.
To allay staff concerns that they would lose their clinical identities and mentorship, the redesign plan calls for clinical specialists for each discipline.
There are clinical specialists for physical therapy and occupational therapy in each program, for speech therapy in brain injury and stroke, and one recreation therapy clinical specialist across programs. Clinical specialists spend 75% of their time in clinical duties and 25% mentoring and teaching.
The objective of the redesign project was to create an approach to patient care that was more responsive to patient needs and at a lower cost per day. Hospital management wanted to make sure the changes would sustain or improve patient outcomes and customer satisfaction among patients, referring physicians, and payers.
Patient satisfaction jumps to 99th percentile
In the first quarter of the new design, patient satisfaction jumped to an all-time high of 90.6%, placing it in the 99th percentile in the Press Ganey Survey database. The average for similar facilities was 86.6%.
"In my opinion, this is important because we already had high patient satisfaction levels," Bergen says.
One aim of the project was to decrease how many staff interacted with one patient, having instead a smaller consistent team working with the patient.
Since the redesign, the number of staff who interact with the patients has decreased by 33.4%, Keating says.
Outcomes data is not available yet.
Although reduced costs per day are expected over time, the cost have not yet decreased, Bergen says. One reason is that the restructuring of responsibilities results in pay increases for some of the affected staff.
Management costs are lower, but direct labor costs are not, Bergen says.
"We need additional time to learn how to increase our efficiencies. We are evaluating all positions when they come open to determine whether that position needs to be filled or whether we can absorb the role," Keating adds.
One of the stipulations of the redesign was that no one would be laid off and the staff would be absorbed into the new roles, Keating says. Salaries were not cut, although opportunities for salary advances may be limited for some staff by the salary levels of their new positions.
The team is now studying how the hospital can manage staffing based on the census, as well as the mix of professional and paraprofessional staff.
"We have been learning a lot about the appropriate staff allocation for each team and how to flex staff time. It’s harder to flex staff time when you establish consistent teams of staff that work with a designated patient population," Bergen says.
When the redesign committee began to talk about designating the team leaders, they encountered some resistance from physicians, who considered themselves team leaders, and from case managers because of their leadership role in managing care, Keating says.
"What we were looking for was someone to supervise and coordinate the teams, someone the staff reports to on a daily basis who evaluates performance," Keating says.
The redesign committee settled on the term "team coordinator" and defined the responsibilities as implementing the program designed by the team under the direction of the physician for medical issues and the case manager for resource utilization.
Candidates for team coordinators could be clinicians of any backgrounds. All current staff were eligible to apply for the team coordinator jobs and were asked to apply for coordinator of whichever program they preferred.
The redesign committee hoped for a mix of professionals in the roles, Keating says. The hospital ended up with five nurses, four physical therapists, and one occupational therapist as team leaders.
Patients are grouped according to diagnosis. Teams are grouped according to space in the hospital. For instance, the two stroke teams are on separate but contiguous units.
Both brain injury teams work on one unit dedicated just to brain injury. Each team is responsible for its own set of patients who are assigned according to the census being treated by each team.
The other specialty programs are on one large unit, but in different pods.
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