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New York Association of Homes and Services
for the Aging
Operational Excellence Primer
Dr. Bob Fazzi 243 King Street, Suite 246 Northampton, MA 01060
413-584-5300 fax: 413.584.0220
e-mail: [email protected] www.fazzi.com
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Operational Excellence
New York Association of Homes and Services for the Aging
©2011
©2011
Excellence Primer
Dr. Bob FazziJune 2011
Approach to Presentation
BIG Picture
©2011
Systems Approach
Whatmakes an
ti l
©2011
exceptional company?
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Think of Organizations That You Believe Are Successful
©2011
W.L. Gore & Associates
• Revenue: Increased by over ½ billion dollars in five years. Annual sales near $2.5 billion.
• Quality: Won over thirty national and international quality awards for its various product lines, from clothing and fabric to geochemical to medical.
©2011
• Customer Satisfaction: Primary source of growth is customer satisfaction and word of mouth.
• Growth: Founded in 1958. Today, approximately 9,000 associates in 50 locations around the world. Annual revenues top $2.5 billion.
• Staff Retention: For the 12th consecutive year, W.L. Gore listed in Fortune’s “100 Best Companies to Work For.” Has also won the same distinction in international locations.
What does a home care agency need to do to be exceptional?
©2011
They Start with the End......the Measurable End
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Your Key Organizational Goals
Profitability
What are the “Measurable Ends”in Home Care?
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Exceptional Quality
Satisfied Patients
Satisfied Referrals
Satisfied Staff
Start by Recognizing the Eight Major Operational Components of a Home Care Agency
Marketing
Clinical Services
Intake
Finances
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Clinical Services
QI/PI
Information Systems
Finances
Medical Records
Human Resources
Understand How These Components Fit Into the Operational Workflow
Referral Source Relationship and Getting Referrals
Receiving & Screening Referrals
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Clinical Assessment/ OASIS/Admission
Care Plan Development
ServiceDelivery &
Documentation
Recertification or Discharge
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Within These Components and Workflow, Leaders Focus on the Five Outcomes
• Leaders focus on all five outcomes, not just one.
• They excel in all five
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They excel in all five outcomes.
• They focus on best practices.
• They know how to get staff committed to the goals.
Knowing What Your Goals are is Not Enough
Your Key Organizational Goals
Profitability
©2011
Exceptional Quality
Satisfied Patients
Satisfied Referrals
Satisfied Staff
You Need Outcomes to Measures
Organizational Goals Outcome Measure
Profitability11.4% Profit/Medicare Episode (MedPAC)
Exceptional QualityTop 20% of Home Health
©2011
Exceptional QualityCompare
Satisfied PatientsTop 20% of Patient Satisfaction Service
Satisfied Referrals5% Growth from Previous Year
Satisfied StaffTurnover less than 15% for all positions
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You Need Leaders to Get the Outcomes
Organizational Goals
Outcome MeasureLeadPerson
Profitability11.4% Profit/Medicare Episode (MedPAC)
Exceptional QualityTop 20% of Home Health C
©2011
Exceptional QualityCompare
Satisfied PatientsTop 20% of Patient Satisfaction Service
Satisfied Referrals5% Growth from Previous Year
Satisfied StaffTurnover less than 15% for all positions
The Strategic Change Model©2011
Bad Realities
• Therapy audits – MedPAC, CMS, RAC, Wall Street Journal, Senate Finance Committee, and now the SEC.
• Greater scrutiny by regulators.
E fit
©2011
• Excess profits.
• Overgrowth in number of agencies.
• Health care reform driven budget cuts – 4.89% in 2011, more expected.
• National growth in cost out of control.
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8,313
8,954
9,403
10,02610,422
Growth of HHAs
©2011
7,056
7,342
7,803
2002 2003 2004 2005 2006 2007 2008 2009
Source: MedPAC, Report to the Congress: Medicare Payment Policy, March 2010
1000
1500
939
The Reality of Home Care – 1967©2011
0
500
Public Health
Other VNA Non Profit Hospital For Profit
549
133132
Source: National Association for Home Care & Hospice, Basic Statistics About Home Care, 2010
1000
1500
The Reality of Change
From 1967 ‐ 2009
1,392 1,311
©2011
0
500
Public Health
Other VNA Non Profit Hospital For Profit
232
516598
Source: National Association for Home Care & Hospice, Basic Statistics About Home Care, 2010
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The Reality of Change
From 1967 ‐ 2009
6500
7000
6,5856,585
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5500
6000
Public Health
Other VNA Non Profit Hospital For Profit
Source: National Association for Home Care & Hospice, Basic Statistics About Home Care, 2010
Home Health Competition
Year Number of AgenciesNumber of Agencies per 10,000 Beneficiaries
2003 7,342 2.0
2005 8,313 2.3
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2007 9,404 2.6
2009 10,961 3.1
2010 11,488 3.2
Source: MedPAC, Report to the Congress: Medicare Payment Policy, March 2011
The number of agencies has increased by 4,146 agencies a year since 2002.
2,643
2,870
3,073
3,258
3,389
Growth of Hospices
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2,349
2,464
2002 2003 2004 2005 2006 2007 2008
Source: MedPAC, Report to the Congress: Medicare Payment Policy, March 2010
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Certified Home Care Medicare Margins ‐ 2007
Category Medicare Margin
Low margin agenciesBottom 20%
‐9.0%
©2011
Bottom 20%
National Average 16.9%
High Margin AgenciesTop 20%
37.0%
Note: Values shown are medians for the quintile. High‐margin quintile agencies were in the top 20% of the distribution of Medicare margins. Low‐margin quintile agencies were in thebottom 20% of the distribution of Medicare margins. Excludes government agencies.
Federal Spending FY 2010
2%
3%
3%
5%
6%
Scientific and Medical Research
Transportation Infrasturcture
Education
Other
Interest on Debt
/
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7%
14%
20%
20%
21%
Federal Retiree/Veteran Benefits
Safety Net Programs
Defense and Security
Social Security
Medicare, Medicaid, CHIP
Source: Congressional Budget Office, 2010. Note: Percentages may not total 100% due to rounding.
Positive Environmental Realities
• Growth in agencies ‐maybe.
• Growth in number of patients.
G h d i i h l
©2011
• Growth and improvement in technology.
• Dramatic shift of Medicaid dollars from nursing homes to home care.
• New opportunities with health reform.
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What the Measurable Goals Are of Successful Companies
1. Profitability: Having profit margins that are significantly greater than norms of their industry – benchmarked.
2. Quality: Being recognized as having better quality than competitors – benchmarked.
©2011
3. Customer Satisfaction: Having customers who rate their product or service better than competitors – benchmarked.
4. Growth: Having customers who return and others who recommend and refer friends for service – benchmarked.
5. Staff: Having turnover rates lower than industry standards in their service area – benchmarked.
Goal I
Profitability
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You Must Respond to Reality
Reality: You had to deal with a 4.89% average decease in revenues starting January 1, 2011 and maybe more to come.
Implications: You will have less profit or go
©2011
Implications: You will have less profit or go into deficit if you don’t do something.
Action: Lower cost by 5%, increase revenue/episode, and increase overall revenue with new services.
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Profit Margin
Case Mix Weight
Cost per Visit
Key Financial Performance Measures
©2011
Days in AR
Staffing Ratio
Clinical Productivity
Care Management/Service Delivery
Profit Margin
NationalAverage
Top Performers
Medicare Profit 11 93% 24 59%
©2011
Medicare Profit 11.93% 24.59%
Home HealthAll Payers
3.55% 15.81%
Fazzi BestWorks® Database, 2011
Case Mix Weight and Revenue
Average Case Mix Weight
Revenue/Episode
$2,192.07*
500 SOC
Net RevenueWhat it
Would Mean
National** 1.31
$2,871 $1,435,500 NA
1.20 $2,630 $1,315,000 ($120,500)
©2011
©2011
$ , $ , , ($ , )
1.15 $2,521 $1,260,500 (175,000)
1.10 $2,411 $1,205,500 ($230,000)
1.05 $2,302 $1,151,000 ($284,500)
1.00 $2,192 $1,096,000 ($339,500)
.95 $2,082 $1,041,000 ($394,500)
*Current CMS Standardized 60 Day Rate for Episodes as of Jan. 2011** National Average CMW at RAP in CMS Final Rules. Nov 2010
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Cost Per Visit
Home HealthProfit Margin
NursingVisits/Day
Cost/Nursing Visit
PT Visits/Day
Cost/PT Visit
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National Average
3.55% 4.11 $155.87 5.22 $141.29
Top Performers
15.81% 3.89 $142.74 4.46 $135.66
Fazzi BestWorks® Database, 2011
“Overhead accounts for 2/3 difference between high margin agencies and low margin
©2011
and low margin agencies.”
GAO Study reported in L&M Home Health Study Report for CMS, January
11, 2011.
Clinical/Administrative Staff Per 100 ADC
Staffing Ratio
©2011
National Average 6.7
Top Profit 5.03
Fazzi BestWorks® Database, 2011
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AR and Cash Management
Days inAR
Days toRAP
Days toFinal Bill
©2011
National Average
56.4 13.27 24.65
Top Profit 42.57 14.93 21.36
1. Functional Approach: Measuring and affecting various functions related to a visit. Lower time for any function results in increased time for more visits.
Financial Improvements Through Productivity Improvements
©2011
2. Management Approach: Ensuring higher productivity by training supervisors to use outcome management and to learn how to hold staff accountable.
3. Productivity Model Approaches: A review of five models used to increase productivity.
Yes.
You can increase
©2011
You can increase clinical productivity.
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Why Do Most Leaders Want to Increase Productivity? To Increase Profit/Episode.
If the Total Cost (Fixed and Variable Cost) per Clinician is determined to be $450/day:
Total CostTotal Visits Per Day
Cost/Visit
©2011
y
$450 4.5 $100.00
$450 5.0 $90.00
$450 5.5 $81.52
$450 6.5 $69.23
$450 7.0 $64.29
Lower cost/visit means more profit per episode…or does it?
What If You Have High Clinical Productivity, But…
• Your quality reports (Home Health Compare) are poor?
• Your time to complete paperwork is double what it takes other agencies?
©2011
• The timeliness and accuracy of clinician paperwork is poor?
• You need to do more visits to help a patient reach a level where they can be discharged?
• Your patients feel they are rushed or not properly cared for and they tell you... and their physician?
Why Comparing Agency Visit Counts Doesn’t Make Sense
Type of VisitPatients Actually Seen
Agency A Counts Visit
Agency B Counts Visit
Agency C Counts Visit
Regular Visit 2 2 2 2
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g
Admission Visit 1 1 2 3
Supervisory Visit 1 0 0.5 1
Training Meeting 0 0 1 1
Total 4.0 3.0 5.5 7.0
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Real Life Example: How 22 Agencies in One State Measured Clinical Productivity
Number of Visits 0 .5 1 1.5 2 2.5 3
Regular Visit 1 21
Admission/OASIS Assessment Visit
3 17 2
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Resumption/OASIS Visit 6 7 9
Recert/OASIS 9 8 4 1
Discharge/OASIS Visit 15 7
Supervisory Visit 6 8 8
In‐service Training 13 7 2‐?
Not Home/Not Found Visit 10 6 6
Weekly Clinical Productivity Report(Standard and Goal for Team: 5.0 Visits/Day)
Nurse Wk 1 Wk 2 Wk 3 Wk 4
A 4.7 5.0 5.0 5.3
B 4.4 4.9 5.1 5.1
©2011
C 4.0 3.9 4.2 4.2
D 5.2 5.1 5.1 5.3
E 5.0 5.0 5.0 5.0
F 3.8 4.8 5.0 5.1
Avg. 4.5 4.8 4.9 5.0
Regular Visit 1 visit
Admission/OASIS Assessment Visit 2 visits
Resumption/OASIS Visit 1 visit
Recert/OASIS 1 visit
Recommendations for What to Count When Counting Productivity
©2011
Recert/OASIS 1 visit
Discharge/OASIS Visit 1 visit
Supervisory Visit 1 visit
In‐service TrainingDon’t count exclude time
Not Home/Not Found VisitDo not count
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Clinical Model
Average RN Caseload 25 Cases
A erage PT Caseload 22 Cases
©2011
Average PT Caseload 22 Cases
Average Time in Home Admission/SOC Visit
90 min
Admission Visit Weight 2 Visits
Fazzi’s Care Management
A program to manage and help ensure the delivery of standardized, outcome based, and cost efficient patient care. Ensure that we only make visits:
• At the right time...
©2011
At the right time...
• By the right discipline…
• For the right purpose…
• That lead to patient specific outcomes.
QPCTop 1/3 Highest
Quality
QPCTop 1/3 LowestHospitalization
QPC Top 1/3 Highest
HHCAHPS
QPCTop 1/3 Lowest
Cost/Visit
Staff
©2011
Practices Process Staff Ratios Structure
Care Management Model
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Practices Process Staff Ratios Structure
Care Management Model
©2011
QPCTop 1/3 Highest
Quality
QPCTop 1/3 LowestHospitalization
QPC Top 1/3 Highest
HHCAHPS
QPCTop 1/3 Lowest
Cost/Visit
Staff
Clinical Model Features:
• Interdisciplinary Teams
• Formal Care Management Standards
©2011
• Weekly Case Management Conferences with Care Manager
• Scheduling by Nurses/Team
Case Conference
• Case conferences are held weekly at a set day/time for each team.
• Attendance is mandatory for the Interdisciplinary
©2011
Attendance is mandatory for the Interdisciplinary Team (excluding HHA).
• Clinical Manager should participate.
• The conference is facilitated by the Care Manager.
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Individualize Your Strategy Based on Your Profit Margins
17% Plus: Ensure and document everything, particularly therapy justification. You may be a target.
10 – 17%: Audit your OASIS assessments. Verify accuracy.
©2011
0 – 10%: Problems. Focus on OASIS and improving service utilization.
0% or Less: Potential crisis. Full operational review. If CMW is lower than 2.0, audit and training will have immediate benefit.
Goal II
Quality
©2011
You Must Respond to Reality
Why Focus on OASIS?
Your quality.
Your revenue.
©2011
©2011
Your plan of care.
Resource determination.
Home Health Compare scores.
The viability of your agency.
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Outcome MeasuresJanuary 2009 – December 2009: Home Health Compare
MeasureYour
AgencyNY
Nat. Avg.
Percentage of patients who get better at walking or moving around
44% 47%
Percentage of patients who get better at 52% 54%
©2011
getting in and out of bed52% 54%
Percentage of patients who get better at bathing
63% 65%
Percentage of patients who have less pain when moving around
65% 64%
Percentage of patients who are short of breath less often
62% 60%
Outcome MeasuresJanuary 2009 – December 2009: Home Health Compare
MeasureYour
AgencyNY
Nat. Avg.
Percentage of patients whose wounds improved or healed after an operation
79% 80%
Percentage of patients who had more pressure sores when home care ended
_ _
©2011
pressure sores when home care ended
Percentage of patients who get better at taking their medicines correctly (by mouth)
45% 43%
Percentage of patients who need unplanned medical care related to a wound that is new, worse, or becomes infected
_ _
Percentage of patients who had to be admitted to the hospital
31% 29%
Process MeasuresJanuary 2010 – September 2010: Home Health Compare
MeasureYour
AgencyNY
Nat. Avg.
Pain assessment conducted 96% 97%
Heart failure symptoms addressed during short term episode of care
96% 97%
©2011
Pressure ulcer risk assessment conducted 94% 95%
Pressure ulcer prevention in plan of care 92% 90%
Pressure ulcer prevention implemented during short term episode of care
88% 88%
Timely initiation of care 92% 87%
Depression assessment conducted 91% 92%
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MeasureYour
AgencyNY
Nat. Avg.
Drug education on all medications provided to patient/caregiver during short term episodes of care
82% 84%
Multifactor fall risk assessment conducted 93% 94%
Process MeasuresJanuary 2010 – September 2010: Home Health Compare
©2011
for patients 65 and over93% 94%
Influenza immunization received for current flu season
66% 66%
Pneumococcal Polysaccharide vaccine ever received
55% 60%
Diabetic foot care and patient/caregiver education implemented during short term episode of care
87% 84%
Bonus Reality
Reality: Control OASIS and you control quality and revenue.
Implications: Do OASIS correctly, you generate
©2011
the funds you need to provide quality services
Action: If your CMW is low (below 1.31 – national average), do an audit and targetedtraining. It will pay for itself in one month.
Accurate and Meaningful OASIS Assessments Are Critical
2 ‐ 3 Hours
OASIS Assessment
HHRG SOC Assessment
©2011
HHRG SOC Assessment
Case Mix Weight Discharge Assessment
$ for Services Home Health Compare
Profit Loss Good ResultsGood Reactions
Bad ResultsBad Reactions
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Impact of Underscoring and Revenue
Average Case Mix Weight
Revenue/Episode
$2,192.07*
500 SOC
Net RevenueWhat it
Would Mean
National** 1.31
$2,871 $1,435,500 NA
1.20 $2,630 $1,315,000 ($120,500)
©2011
©2011
$ , $ , , ($ , )
1.15 $2,521 $1,260,500 (175,000)
1.10 $2,411 $1,205,500 ($230,000)
1.05 $2,302 $1,151,000 ($284,500)
1.00 $2,192 $1,096,000 ($339,500)
.95 $2,082 $1,041,000 ($394,500)
*Current CMS Standardized 60 Day Rate for Episodes as of Jan. 2011** National Average CMW at RAP in CMS Final Rules. Nov 2010
What We Now Know From OASIS TestingInsights from the OASIS Competency Institute
Skills Assessment Testing
• Conducted by the OASIS Competency Institute.
• Competency Institute is an outgrowth of the National OASIS‐C Best Practice Project – Delta/NAHC/Fazzi.
©2011
• Comparison of last three test periods:
• 6,800 clinicians in June 2010• 7,900 clinicians in September 2010• 8,800 clinicians December 2011
• Breakdown of Clinicians:
‐ Auditors: 4% ‐Managers: 9% ‐ Other: 2%
‐ Nurses: 60% ‐ Therapists: 25%
Score by Discipline
80
90
100
87%85%
77%79%79%
81%
74%76%
98% 97%
84% 84%
June
©2011
40
50
60
70
Auditors Managers Nurses Therapists
June
September
December
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Range of Scores
60
70
80
90
100100%
75%
100%
76%
100%
84%
June
©2011
37%37% 32%
10
20
30
40
50
High Low Average
37%32%
37%
September
December
Reality: Number of Home Health Compare quality scores will increase and will be more closely scrutinized, particularly hospitalization
Implications: Increase use of scores by hospitals
©2011
and other systems making decision on who to work with.
Action: Go for top 1/3 in quality scores.
Four Immediate Answers
• Revamp your care management model – deal with cost and quality at the same time.
• If CMW at RAP is below 1.31, conduct an audit and targeted training
©2011
targeted training.
• Test and track clinician, department, agency competency. Use low cost OASIS Testing products.
• Focus on hospitalization. It is the #1 measure being looked at by all segments of the health system.
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What if You Knew...
2004 2005 2006 2007 2008
Inpatient ‐0.3% ‐0.5% ‐2.2% ‐3.7% ‐4.7%
Hospitals throughout the United States are losing money on their Medicare business
©2011
p
Outpatient ‐10.7% ‐9.1% ‐10.9% ‐11.6% ‐12.9%
Overall Medicare
‐3.1% ‐3.1% ‐4.7% ‐6.0% ‐7.2%
Source: MedPAC Report to the Congress: March 2010
• Health Reform and CMS are now focusing on hospitals and demanding that they reduce avoidable re‐hospitalizations.
• Effective October 1, 2012, hospitals will be asked to reduce the re‐hospitalization of patients with three conditions:
What if You Knew...©2011
p p
• AMI ( Anterior Myocardial Infarction or Heart Attack)
• Pneumonia
• Congestive Heart Failure
• The very conditions hospitals must reduce are conditions that are part of home care’s core business.
• The answer to the hospitals’ dilemma is post acute services. Two out of five discharges go to post acute.
• Home care is the number two post acute service on initial referrals. 16% of all discharges go to home care.
What if You Knew...
©2011
• Home care is the number one post acute service when patients are transferred from one post acute care to another. Three out of six sub acute sites send patents to home care.
• Home care is the answer to the hospital’s dilemma.
Source: MedPAC Data Book, June 2008
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But…29%
©2011
29%
Why Such a Strong Focus on Hospitalizations in Home Care?
Average Cost/Medicare Preventable Hospital Readmission
$7,200*
Total Home Care Patients Served 2008 3,200,000
©2011
*Source: MedPAC, Report to the Congress: Promoting Greater Efficiency In Medicare, Payment Policy for Inpatient Readmissions, June 2007 (Average payment in 2005); Home Health Compare, Risk-adjusted Home Health Outcome Report for Utilization Outcomes January 2009 to December 2009; American Hospital Association, Trendwatch, November 2010 (Medicare Payment Advisory Commission (June 2010), Data Book: Healthcare Spending and the Medicare Program
Percentage of Home Care Patients Re‐hospitalized 2009
29%
Total Patients Re‐hospitalized 2008 928,000
Total Cost for All Home Care Patients Re‐hospitalized 2008
$6.7 billion
If We Can Reduce Unplanned Hospitalizations, What Would it Mean in
Dollars Saved?
Percent of Home Care Patients Re‐hospitalized
2009 Percent 29%
If 27% If 23%
Home Care Patients928 000 864 000 736 000
©2011
Home Care Patients Re‐ hospitalized
928,000 864,000 736,000
Dollars/Patient Re‐hospitalized
$7,200 $7,200 $7,200
Total Dollars for All Episodes
$6.7 B $6.2 B $5.2 B
Savings NA $0.5 B $1.5 B
*Source: MedPAC, Report to the Congress: Promoting Greater Efficiency In Medicare, Payment Policy for Inpatient Readmissions, June 2007 (Average payment in 2005)Home Health Compare, Risk-adjusted Home Health Outcome Report for Utilization Outcomes January 2009 to December 2009
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If We Can Reduce Unplanned Hospitalizations, How Many Fewer People
Would Be Hospitalized?
Number of Home Care Patients
NumberRe‐hospitalized
Number of Fewer People Re‐hospitalized
©2011
pPresent Percent 29%
3,200,000 928,000 NA
If 27% 3,200,000 864,000 63,217
If 23% 3,200,000 736,000 192,000
*Source: MedPAC, Report to the Congress: Promoting Greater Efficiency In Medicare, Payment Policy for Inpatient Readmissions, June 2007 (Average payment in 2005)Home Health Compare, Risk-adjusted Home Health Outcome Report for Utilization Outcomes January 2009 to December 2009
There Are Concrete AnswersFazzi/Briggs Reducing Unplanned Hospitalization Study
• Fifteen distinct strategies were identified by the field.
• Most agencies used more than one strategy
©2011
g gy(Average 6.4).
• The top five strategies did not cost money.
• Agencies who were successful were also very “intentional” in their efforts to reduce hospitalizations.
What Were the Intentional Strategies That Emerged From the Study?
• 24 Hour Availability/ Response
• Case Management
•Data Driven Services
• Front Loading Services
•Management Culture & Support
•Medication Management
©2011
•Data Driven Services
•Disease Management Program
• Fall Prevention
•Hospital Relationships (D/C Planning Staff)
•Hospital Relationships (ER)
•Medication Management
• Patient Caregiver Education
• Physician Relationships
• Safety/Risk Assessment
• Special Support Services
• Telehealth
25
How Frequently Were the Various Strategies Used?
• Fall Prevention (83%)
• Front Loading Services (71%)
• Management Culture & Support (69%)
di i
• Special Support Services (52%)
• Disease Management Program (43%)
• Data Driven Services (43%)
©2011
• Medication Management (64%)
• 24 Hour Availability/ Response (63%)
• Patient Caregiver Education (57%)
• Case Management (56%)
• Data Driven Services (43%)
• MD Relationships (40%)
• Safety/Risk Assessment (38%)
• Hospital Referral Relationship (23%)
• Telehealth (11%)
• ER Relationship (9%)
Goal III
Patient Satisfaction: CAHPS
©2011
You Must Respond to Reality
Reality: Patient satisfaction will now count and be reported on HH Compare.
Implications: Doctors, hospitals, your staff and board patients family
©2011
and board patients, family members, etc. will look at national CAHPS scores.
Action: Achieve top 1/3 in CAHPS.
26
Five
©2011
Five
CAHPS Has Their Own HHC Measures
3 Composite Measures:• Care of Patients (Q9, Q16, Q19, and Q24)
• Communication between Providers and Patients (Q2, Q15, Q17 Q18 Q22 and Q23)
©2011
Q17, Q18, Q22, and Q23)
• Specific Care Issues (Q3, Q4, Q5, Q10, Q12, Q13, and Q14)
2 Global Measures:• Overall Rating of Agency Care (Q20)
• Would you Recommend this Agency to Friends and Family? (Q25)
How Would Your Agency Rank on This Global Question?
Would you recommend this agency to your family or friends if they needed home health care?
©2011
care?
Definitely Yes
Probably Yes
Probably No
Definitely No
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What Do Patients Think Bad Service Is?
• “Not all the nurses knew the treatment.”
• “Didn’t tell me ahead of time when someone is coming.”
©2011
• “Constantly sending different people.”
• “Not coming when you say you are going to come.”
• “Making me feel like you are rushing.”
85%
89%
Overall Rating of Care
Care of Patients
Fazzi National Database
HHCAHPS: Initial Results©2011
81%
82%
85%
85%
Likelihood of Recommending
Specific Care Issues
Communications Btwn Providers and Patients
Overall Rating of Care
93%
94%
Overall Rating of Care
Care of Patients
Fazzi National Database
HHCAHPS: Best Practice Results
©2011
91%
89%
91%
93%
Likelihood of Recommending
Specific Care Issues
Communications Btwn Providers and Patients
Overall Rating of Care
28
Patient satisfaction and CAHPS
scores will be the single most
important strategy for
©2011
important strategy for
differentiating your agency
with patients, referral sources,
and even staff.
Four Immediate Answers
• Develop a full customer service program.
• Use aggressive QI initiatives for all problem areas.
©2011
• Build customer service into your agency, team, and individual clinicians tracking and reporting systems.
• Strive for the top 1/3 in CAHPS reported scores.
Goal IV
Staff
©2011
You Must Respond to Reality
29
Reality: Those who have good staff win; those who don’t…
Implications: Agencies must strive to do everything they can do keep
©2011
y g y pgood staff.
Action: Establish QWL programs that help you retain your best staff and have turnover below 15%.
There is One Number That is Key to Dealing With Your Staffing Challenges
©2011
Financial Realities of Retaining Staff
• Study of four hospitals with 26.8% turnover rate : Cost of replacing nurse: 1.37 x salary. (Journal of Nursing)
• Study of one hospital with 23% turnover rate: Cost: 1.31 x salary.(Nursing Economic)
• Study of six hospitals: Cost: 2.1 – 2.6 x salary.(
©2011
(Nursing Watch)
• Study of four units in six countries: Cost: $21,514.(37th Biennial Convention)
• Study of one hospital with 29% turnover rate. Cost: 1.7 to 2.0 xsalary. (Health Care Management Review)
• Study of one hospital. Cost 2.1 to 2.3 x salary.(Journal of Nursing Administration)
30
Five Immediate Answers
• Develop a full customer service program.
• Make staff retention and staff satisfaction measurable outcomes that you hold your supervisors accountable for
©2011
for.
• Use rounding.
• Set standard of turnover being no higher than 15%.
• Conduct annual Staff Satisfaction Survey.
What an Employee Satisfaction Study Can Do for Your Agency
• Tell you what your staff think about their employment experience.
• Tell you how different disciplines view your agency.
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• Tell you how departments view your agency.
• Tell you how any segment you choose views your agency.
• Tell you what areas you can improve (by segment) to enhance the work experience, motivation and retention of staff.
Why Supervisory Management Training is So Critical to Retaining Staff in Home Care
• Length of Study: Twenty‐five years.
• One Goal: What leads to retention of staff?
• Finding: While there are many reasons why an employee
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d g e t e e a e a y easo s y a e p oyeeinitially takes a job in an organization, how long that employee stays with the company and how productive he or she is while there is determined primarily “by their relationship with his or her immediate supervisor.”
• Focus: One million workers and eighty thousand managers in four hundred agencies.
Source: Break All the Rules: What the World’s Greatest Managers Do Differently. Marcus Buckingham & Curtis Cuffman
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Another Gallup Study Shows It’s All About Feelings
Three critical factors that predict if an employee is “engaged” ‐ and engaged employees are 50% more likely to be motivated, productive and stay in their jobs.
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• The employee feels cared for by their supervisor.
• They received recognition or praise during the past seven days from someone in a leadership position.
• They believe their employer is concerned about their development.
Why is Focusing on the Supervisor Soooooooo Critical?
“People don’t leave companies – they leave leaders.”
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leaders.
Richard LeiderAuthor and Internationally Recognized
Leadership Coach
Goal V
Growth
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You Must Respond to Reality
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Reality: Home care is moving to a more competitive environment and new ways of doing things.
Implications: New program options and growth will be key to your
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growth will be key to your future
Action: Improve your relations with existing referral bases and participate with the new reality with one new model.
What We Know From Fazzi’s Agency Referral Source Surveys
1. More than 10% are dissatisfied with services that they receive from agencies.
2. Nearly 25% feel that they do not have the right amount of contact and communication with an agency
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communication with an agency.
3. Nearly 50% identify specific agencies where they view the quality of services as better than competing agencies but…
4. Most have clear ideas for how the agency can be more valuable to them.
Four Immediate Answers
• Develop a full customer service program.
• Initiate immediate efforts to increase penetration with existing referral sources.
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• Initiate efforts to expand existing
• Initiate one major effort to collaborate and develop a new program response to reducing unplanned hospitalizations – ACO, Medical Home Model, Care Transition Program.
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Reality: Health care reform will lead to numerous new business options.
Implications: If you focus on one option, you can grow in size and
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you can grow in size and profit.
Action: Focus on partnering with hospitals to reduce readmissions.
To Control Your Goals, You Must Go Beyond Simply Naming Them
1. Competitive financial outcomes.
2. Competitive clinical outcomes.
Outcomes are not measurable.
No way to measure success.
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3. Competitive patient satisfaction results.
4. Competitive number of referrals.
5. Competitive retention of staff.
No way to reward people who
exceed outcomes.
No way to hold people
accountable.
No way to set standards for agency.
Know Your Targets
Organizational Goals Outcome Measure
Profitability 11.4% Profit/Medicare Episode (MedPAC)
Exceptional QualityTop 33% or top 20% of Home
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Exceptional QualityHealth Compare
Satisfied PatientsTop 33% or top 20% of CAHPS Patient Satisfaction Survey
Satisfied Referrals 5% Growth from Previous Year
Satisfied StaffTurnover less than 15% for all positions
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Name a Lead Person
Organizational Goals Outcome MeasureResponsible
Person
Profitability10.0% Profit/Medicare Episode (MedPAC)
Exceptional QualityTop 33% or top 20% of Home
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Exceptional QualityHealth Compare
Satisfied PatientsTop 33% or top 20% of Patient Satisfaction Service
Satisfied Referrals5% Growth from Previous Year
Satisfied StaffTurnover less than 15% for all positions
“It is not enough to do b t t
To Improve Your Outcomes, Consider the Advice of the World’s #1 TQM Guru
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your best, you must KNOW what to do, and then do it.”
W. Edward Deming
A Quick Strategy ReviewProblems, Goals and Strategies
Problem Proof Goal StrategyInside/ Outside
Timeline
Low CMW Scores
CMW at RAP: 1.15
Imp. CMW Audit & TrainOutside 2 Months
Poor Quality
Bottom 1/3 in HH Comp.
Top 1/3Train, Sup Visits, QI Effort
Inside15 Months
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Low Productivity
Below Adm. Average
Achieve Avg.
Liaison visit, trn, compellargu.
Inside 9 Months
Low PS Bottom 25% Top 25%Benmk top 25%, Trn
Inside 12 Months
Low Referrals
Losing Mkt. Share, No Growth, Slow Growth
Increase Mkt. Share
Ref Study or CS Program and Targeted Strategies
Outside/ Inside
6 Months
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Problems, Goals and Strategies
Problem Proof Goal StrategyInside/ Outside
Timeline
High Cost/Visit
10% above national average
Lower by 10%
Review all benchmarks, cross discipline task group.
Inside 3 Months to 12 Months
S ff S
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Staff Turnover
Avg. above 17% Annual
Below 10%
Staff Sat. Study or CS Program and Targeted Strategies
Outside/ Inside
9 Months
Multiple Problems: Low Profit and Low Quality
Minimal and/ or Low Profit and Low Quality
Top 1/3 in both
Operational Review
Outside 6 Months to 18 Months
A Rule to Remember
• Successful change is measured by the end result:
Did you complete the change in a
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Did you complete the change in a timely manner and did you get a quality outcome with maximum levels of public and private acceptance?
Note: Not all changes will result in everyone being happy.
Importance of Leadership for Change
“The one thing that distinguished successful projects from less successful ones was not money, the idea
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or the importance of the project. It was the leader”.
Dr. Steven SchroederPresident/CEO
Robert Wood Johnson Foundation1990 ‐ 2001
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Make Sure You Have the Right Leader for Your Project
1. Goal oriented
2. Has the skills to succeed
3 I lf ti t d
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3. Is self‐motivated
4. Is self‐confident
5. Can generate excitement and support from those that need to come through or support the effort.
6. Is not afraid to be held accountable.
Of You Want to Make Changes, Remember Management’s Number One Rule
If all you do
Is all you've done,
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y ,
Then all you'll get
Is all you've got.
Nothing will change unless you introduce changes.