An interview with Charleen Weismantel, RN, director, Prairie Lakes Home Care Services
57 minutes. That’s how much work time Prairie Lakes Home Care Services shaved off the typical patient visit, freeing staff up to take on additional home care patients and other duties. In 2005, the department averaged 2.68 hours per patient visit (which includes all home health staff time). Now the department averages 2.11 per visit—which is even better than their 2.24 benchmark.
The time savings came from examining and improving inefficient and cumbersome work processes. No changes were made that negatively impacted patient care. In fact, the department has maintained good clinical outcomes. “We have not compromised patient outcomes in order to realize better productivity,” says director Charleen Weismantel, RN, director. We don’t want to sacrifice good patient care at the altar of financial issues.”
The home health department had an excellent role model: Prairie Lake’s own medical-surgical unit, which met a productivity benchmark of 7.5 hours per patient day while also improving nurse turnover and patient satisfaction. (For details, see the July-August 2008 issue of The Business of Caring). The unit was a pilot participant in the Transforming Care at the Bedside (TCAB) project, which provide tools and support for engaging front line staff in rapid cycle improvement efforts.
The Prairie Lake Health System is now concentrating on “spreading” the positive examples from the medical-surgical unit to home health and other departments. In the following Q&A, Weismantel shares some of the improvements made at Prairie Lakes Home Care Services that has helped improve productivity and efficiency.
When did Prairie Lakes Home Care first start looking at improving work processes?
Weismantel: During the TCAB project, we looked at our discharge planning process across the health system. That was one of the starting points for us. We started to identify and receive the “spread” of what was happening on the inpatient side.
The hub of our former discharge planning process was the discharge planning/utilization review nurse. We had nurses who went through the charts to identify utilization review issues as well as patients who might need discharge planning. Now we have just one utilization review nurse for the entire facility who concentrates exclusively on utilization review, and we have social workers who handle our discharge planning. This was a good move in my mind since discharge planning and utilization review are two entirely different goals.
We also moved to an interdisciplinary team approach. Every morning, a team (the social worker, utilization review nurse, therapists, home health RN, pastoral care, and bedside nurse) meet to discuss the current and long-term needs of each patient. The team identifies discharge needs together, and the social worker puts together the actual discharge plan.
As a result, our communication has improved dramatically. We know what healthcare issues each patient is struggling with. We also know where the patient is in the patient education process because the inpatient and outpatient sides use the same educational packets, which we purchased through a vendor. For example, when we take on a patient who is discharged with diabetes, we know how far the inpatient side has gotten in the diabetes education packet. Then we pick up the teaching and add some more stuff related to home care. The patient is issued a loose-leaf notebook on discharge from the hospital that we can just add to. The patient can then take that notebook to the clinic or bring it back into the hospital. I think we’ve increased the continuity between inpatient units and the home health and hospice departments. It has saved a lot of time on both sides.
Prairie Lakes recently invested in an integrated information system and electronic medical record. How has that helped improve productivity and efficiency?
Weismantel: Once we get the referral, we can capture a lot of the inpatient data through the information system. We can go online and get the discharge summary (or HMP), the current medication lists, a list of the labs the patient has had, etc.
This has really made a big difference for us. In the morning, the home health nurse can log onto her computer and her patients are downloaded right onto her computer. She can review their medical records from the hospital side. She can see what the HMP said, what the nurse before her said, etc. The home care nurse then goes and sees her patient, completes her documentation, and uploads it into the system. If a patient ends up in the emergency department or back at the hospital, the hospital staff can see what medications the patient was on at home, decreasing the risk of medication errors and all those sorts of things.
What about work processes specific to home health? What have you done to improve these? Did you adopt any ideas from the medical-surgical unit at Prairie Lakes?
Weismantel: We’ve added a staff position called the “resource nurse,” which is an idea we borrowed from the med-surg unit. The resource nurse plans for the home care visits, especially on the new patients. She gathers all of the supplies. She helps to initiate and start the care planning process from the documentation we receive from the inpatient side at Prairie Lakes or from other facilities. She makes sure that we’ve geographically placed the patient into a team that can manage that patient long-term. She does all of those things. The resource person has also assumed the quality assurance processes. In addition, she has become the person that can be called in for a pain consult or a wound consult or hospice palliative care consult.
The creation of our resource nurse position is one of the biggest things we’ve done for saving time. Adding a person doesn’t feel like it would save time, but it really did. Our resource nurse plugs all those holes that exist so you don’t have to pull a home care nurse away from the patient’s bedside. It allowed for the nurses who are actually doing the care in the home to have less fragmentation to their day.
Prairie Lake’s med-surg unit has an improvement team of frontline staff who identify and implement improvement ideas. Do you have a team like that?
Weismantel: Yes, we do. Right now our team is unpackaging our palliative care process. I use the term “unpackage.” It’s kind of like flowcharting. We identify all the steps in the process. We’re the department that handles palliative care family conferences. So when were “unpackage” this process, we detail how we receive and respond to those referrals. If a phone call comes in, what do we do next?
We use color-coded stickies to identify what we’re currently doing and where the bumps in the process are. We use different colors for ideas that might be good to try. Then the team babysits that idea until we identify the best way to fix something.
What other time-saving changes have you made that have helped improve productivity?
Weismantel: We used to require the nurses to print all of their notes and file them. We don’t do that any more. They don’t print any of their notes, so they save time there. In fact, they don’t have to print anything. We used to have the nurses come into the office and print physicians’ orders and make sure that they got mailed out. We’ve developed a new system where the nurses and therapists can have physician orders print out at the printer in our main office. Then our office staff mail and file the orders.
We’ve also worked interdepartmentally to decrease the time spent waiting for medications. Home care nurses used to have to wait for the pharmacy to open up in the morning to get patients’ medications. Now the nurses can call in the meds the day before. They can call from their patients’ homes and reorder meds. Then the resource nurse goes down that same day, picks up the meds for tomorrow, and puts the meds in a locked storage area. So home care nurses can pick up the meds early in the morning instead of waiting for the pharmacy to open up.
We also gave each home care nurse and therapist a cell phone so they can make and receive phone calls whenever they need to. This works better than having to borrow a patient’s phone or waiting to make all their calls at the end of the day, which doesn’t always work real well.
These sorts of process issues seem pretty small, but they are really frustrating. If you can take care of these things you can save staff quite a bit of time that they can apply to patient care.
Do you have any advice for other home care leaders who are hoping to use this kind of approach?
Weismantel: You need to mentally acknowledge and value your staff. Because they are probably the most creative resource you have in terms of changing processes. That’s really, really important. At first, it may feel like you’re wasting time by pulling your staff around the table. But we’ve proven over and over that we need to get together and attack inefficient processes, or they don’t go away. The creativity of your staff is imperative.
How did you motivate staff to participate in this?
Weismantel: When we started this whole process, it probably was driven—initially at least—by the term “productivity.” Finance said the goal was to improve productivity. We weren’t exactly excited about that. We assumed that would lead to poorer patient outcomes, and it wasn’t true at all. So I think acknowledging and looking at the sacred cows that you have, or the ways that you think of things, is where you’ve got to start.
As we began to make the changes we saw right off the bat that this wasn’t about how fast nurses could move. It wasn’t that at all. It was about fixing things that got in the way of nurses’ work—things that were often beyond the nurses’ control. Once we got those problems out of the way, we exceeded our productivity target.
But I have to be absolutely honest. If finance hadn’t said you need to improve productivity, it probably wouldn’t have improved. A lot of the changes were driven by that challenge. It was only when we linked arms that it really happened.
Charleen Weismantel, RN, is director of Prairie Lakes Home Care Services in Watertown S.D. (Charleen.Weismantel@prairielakes.com).