Monday Morning Manager

You’re Hired!

2008-07-21T13:45:00Z

Perhaps you've been there before. You're a department manager in a large academic center in a metropolitan area. You have vacancy rates in excess of 10 percent, and your hospital just added a new 100-bed critical care tower that will require an additional 12 therapists. Competing with at least a dozen other hospitals in your market area for staff, you develop a new skip in your step every time a new application comes across your desk.

The interview's been scheduled. You nervously pace the halls awaiting the arrival of your 10:00am appointment - praying they don't walk into your office with a pack of Marlboros rolled up their sleeve. Having a valid license, a head on their shoulders and a willingness to work the midnight shift is good enough for you.

As the interview starts, you exchange pleasantries with the applicant. "How are you doing?" you ask.

"A little stressed," says the applicant. "I just left an interview from Mercy Hospital, and had another scheduled before that at Trinity. Yesterday, I interviewed with the manager at University Hospital. So far, I've had three offers... right now my head is spinning."

Hook, line and sinker. The bait's been set and you oblige by walking right into the trap. Before you know it, the interview's over and you've just spent the last 45 minutes doing your best used car salesman impersonation.

"We offer a competitive benefits package, and can give you 25 paid vacation days per year" you instruct the applicant. "With your experience, we can offer you $26.00 per hour. Blah, blah blah, blah blah."

You detail your department's consult program, and even let them slide their hand across your new fleet of ventilators. Right on cue, you offer the applicant one of your vacant full-time positions. "You'd be perfect for the job," you say. "I hope you accept."

As the applicant leaves your office, you say your goodbyes. "Thanks Linda, it's been a pleasure to have met you."

"It's Lisa" she says.

Does this sound familiar? How many times have we caught ourselves doing more selling than interviewing... more talking than listening?

The fact is we're all desperate for staff. While it's important to give applicants a clear understanding of what the department's like, selling them on a position that may not be the right fit can lead to devastating consequences.

What happens six months down the road and they've already been counseled for absenteeism, have had three altercations with your medical director, and two complaints from patients?

After you consider advertising expenses, a 90-day orientation, overtime and administrative costs, it may cost an organization in excess of $20,000 every time there is turnover in staff and a new hiring process begins.

While blindly hiring a candidate will provide a warm body for the department, it may prove to be penny wise, but dollar stupid.

Do yourself a favor. Take the time to properly interview applicants. Revert back to your interview skill you learned when life was much simpler and therapists were in abundance. You'll be glad you did it.

Be the Captain of Your Budget

2008-07-17T17:02:00Z

How many times have you heard it? "You're going to have to do more with less."

The notion of running leaner departments has become the norm in respiratory therapy and in healthcare as of late. Those who are at a surplus in staffing are now the exception rather than the rule. So what's a manager to do with budget season looming when manpower needs suggest one number and your hospital labor budget provides you with one quite different?

The answer may be easier than you think!

Know your productivity. Understanding how earned labor is calculated, and what drives productivity is a must. Is it based on units of service or time standards per procedure? Are there adjustments that are made to accommodate travel time, physician interactions and documentation? Are there standards in place that re-align you with other departments of similar size and responsibility? Without this information, it's nearly impossible to argue the need for additional staffing.

Network with your peers. Understanding the staffing levels of others (especially those in your market-place) is paramount, whether you receive this information through a professional list-serve; by interacting with managers at local, state or national meetings; or by comparing data with others in your health system. Hospital administrators would suggest that a national benchmarking report is sufficient data, but what they fail to realize is that this data is typically "one size fits all." Trying to fit a square peg (i.e. respiratory care) into a round hole (all other disciplines) may work, but only after it's been hit with a sledge hammer a few hundred times. Using a benchmarking program like the one developed by the AARC - developed by RTs for RTs - is a much easier method of comparing department operations.

Own your data. Hospital staffing budgets are created by people (aka "bean counters") who believe they know your department operations better than you do. They'd like for you to believe that their spreadsheets and benchmarking reports are like diplomas hanging on their walls that validate their expertise in this area. The truth is, few if any, even have a clinical background. They're relying on information from others to dictate your staffing needs. You're the content expert in this area... why wouldn't they get that information from you? As department manager, it's your job to validate your needs. Use your own data as an ally to earn additional labor. Collecting data such as % overtime, missed treatments, medication errors, volume trends and case-mix index are all great places to start. Utilization of the AARC Uniform Reporting Manual and Benchmarking Project are great tools to get you started.

Build a business plan. Just as with any other capital investment, hospital administrators and finance officers require business plans to support the approval of human capital. Building a business plan that focuses on patient safety, enhanced quality, and missed revenue opportunities will speak to the need. You'd be amazed at what may happen when you use the information highlighted above, package it professionally and speak to them in a language that addresses the business side of healthcare.

One of the biggest reasons why managers fail in their quest for additional staffing is because they sit idly by on the sidelines while others make decisions for them. Getting involved in the process is the first step. When armed with the right information and presented in the right way, there's no telling what opportunities are in store for your department.

Respiratory Therapy 2028: Visions of the Magic 8-Ball

2008-07-07T12:14:00Z

Many people across the country celebrated the 4^th of July with fireworks, backyard barbecues and visiting family. These acts are a celebration of the birth of a free country. On July 4^th of 1776, our forefathers signed the Declaration of Independence which forever allowed us to become (as Frances Scott Key wrote in our national anthem); the "Land of the Free and Home of the Brave."

As we commemorate the birth of our country, it should also be noted that last year, the AARC celebrated its 60^th birthday. Sixty years... while it may sound like a lot, in retrospect; our profession is still in its infancy when compared to professions like nursing, and medical doctors. The time has flown by. We've gone from inhalation technicians, chest cuirasses, and MA-1s, to where we are today; registered respiratory therapists, neonatal-pediatric specialists, and asthma educators using oscillators, closed-loop ventilators, and breath-actuated nebulizers. We've come a long way in the last sixty years... where do you think we'll be in sixty more?

There's no doubt, our profession will continue to grow and evolve. With new technology and the ever-changing landscape of healthcare, the profession must either adapt, or die. While it's purely speculative, I believe in another sixty years, our profession will have changed so much that our forefathers of respiratory therapy would not even recognize it. Anticipating what our profession will look like in 2068 would be impossible, but let me look into my Magic 8-Ball and try see if I can't identify what respiratory therapy will look like in the year 2028.

To no avail, the healthcare industry did everything it could to prepare for the sudden surge of patients (aka Baby-boomers). Hospitals became bigger, technology continued to advance, but manpower shortages continued to plague the healthcare environment. To combat this issue, the RT profession was forced to adapt into an even more specialized workforce.

In 2015, respiratory therapists were recognized as "professionals". There was only one professional credential; the RRT, licensure law in 10 states required a bachelor's degree to practice, and more than 30 programs nation-wide offered a master's level education in respiratory therapy. Healthcare moved from the hospital to the home. Now, RTs were given unsupervised responsibility to treat the patient outside the hospital, prescribe medicine and under the auspices of a physician, were given admitting privileges to hospitals.

By 2020, CMS attacked respiratory therapy licensure laws. Patients by the thousands missed prescribed respiratory treatments on a daily basis because of lack of human capital to deliver the care. Soon nursing assistants, other unlicensed caregivers, and EMTs were delivering bronchodilator therapy to patients on med/surg nursing floors. Technology of MDIs and nebulizers had advanced to the point of breath-targeted aerosol delivery. Proper administration technique became less of an issue, and anyone capable of providing the patient with the device could do so. Aerosol delivery was viewed as more of a remedial task. Raised to the level of a specialty practitioner or physician assistant, therapists wrote all respiratory orders for patients on nursing units.

Clinical RTs worked exclusively in the critical care areas of the hospital caring for only the sickest of patients. They performed bronchoscopies, line insertions and all intubations. They also assumed complete management of ventilators. Median salaries jumped to a mind boggling $120,000/year.

By 2028, the Baby-boomer bubble had burst. There became an overabundance of therapists, nurses and doctors. People lost their jobs and the American economy (after 12 years of a bull market) entered into a recession not seen since 2008. The number of practicing RTs in the United States fell below 100,000 for the first time in almost 50 years. Only the brightest and most highly educated therapists maintained employment in the hospital and in the home. They maintained their niche in the American Healthcare system however; with an enhanced presence in manufacturing and product development, research and disease management.

While I may be looking at my Magic 8-Ball with blurred vision, I would welcome you to provide your visions of the future to the community. Perhaps some may even be as far-fetched and outlandish as mine. If enough of us respond, one of us is bound to be right!

Mandating the RRT Credential... Is it Worth the Risk?

2008-06-27T15:48:00Z

RRT vs. CRT -- the debate has been ongoing for as long as there have been two recognized credentials in our profession. There really are two camps of thought on this hotly debated issue. The AARC and the NBRC suggest that the RRT credential exemplifies excellence in our profession -- a commitment to quality, improved outcomes, and patient care.

Respiratory therapists possessing the CRT credential suggest the exact opposite. They would argue that quality outcomes and improved patient care have little, if anything, to do with the credential, but rather the caregiver delivering the care. CRT supporters typically hang their hats on comments like "I know CRTs with 20 years of experience who can work circles around most RRTs. Changing their credential is not going to make them any smarter or more valuable to their organization. Why should they have to take an exam to validate that they're good at what they do?"

While I'm a supporter of the RRT credential, my intent is not to debate the issue.

Recent decisions from the NBRC have added fuel to the fire. Graduate respiratory therapists now only have a three-year window to sit for and take the RRT credentialing exam. After three years, those CRTs who choose not to sit for the RRT exam must re-take the CRT exam to re-establish registry eligibility. In addition, mandating the RRT credential as a stipulation of employment has gained popularity and momentum in respiratory care departments. So what do you do if you're one of those departments looking to take that leap of faith and require the RRT credential?

There are several questions to ask yourself before making the decision to become an all-RRT department:

What is the supply of human capital with the RRT credential in your market area?
What is the supply of human capital that is registry eligible in your market area?
What is your current vacancy rate?
Can your department budget absorb the increase in salaries by requiring the RRT credential?
What percentage of your staff would be affected by the decision?
How many staff members are registry eligible vs. those that are not?
Would currently employed CRTs be "grandfathered" in or would they be required to meet department mandates?

While the decision is right for some, it's not right for others. A year ago, Fairview Hospital made the decision to become an all-RRT house. The decision was made with much thought and consideration and was supported by administration and our medical director. The only outstanding concern was about our ability to staff the department and attract future candidates.

Weighing all of the options, we elected to pull the trigger. We grandfathered in all non-registry eligible CRTs, mandated registry eligible CRTs to become registered within six months, and made employment offers contingent on the RRT credential or obtaining the credential within six months of hire.

The decision was made with little fanfare or criticism from the existing staff. Most registry eligible employees actually looked at it as an incentive and motivation to do something they always wanted, but always had an excuse not to do. As for attracting new therapists, our pool of candidates has never been better. It's almost as if the decision was made without so much as a blip on the radar screen. We're viewed as a more professional group of therapists with a higher skill set and more expertise.

Should you make the same decision? That's not for me to decide. I will tell you that, in retrospect, we're glad we made the decision we did. The concerns we had didn't come to fruition, and what was once perceived as a potential weakness of our department is now viewed as a strength.

Unfortunately, this decision isn't one that you can wade into. It's a leap of faith that you either make or you don't. Does your department have what it takes to make the leap?

If you've made this decision as well, I would encourage you to share your experiences with the community. Please identify the pros and cons of the decision and how it's affected your department. I would also welcome comments from those who are against such decisions and why. Healthy dialogue is good for the soul!

The Buck Stops Here

2008-06-20T17:19:00Z

Probably one of the most difficult things to do as a manager is to make decisions. Some are quite easy while others are not. While we all would love for our decisions to be celebrated with excitement and fanfare, the simple truth is that rarely does it happen that way. Instead, our decisions are often second guessed, questioned, and leave people scratching their heads.

As a manager and agent for your employer, you're paid to make decisions that are in the best interests of the organization. While your administrator may look at you and say "nice job", your subordinates may ask, "What were you thinking?"

Such was the case this week for me when I had to make one of the most difficult decisions of my career.

Last August, I hired four students as limited permit employees at our institution. They were all very motivated, talented and eager to learn. One woman, who I'll refer to as Sarah, was at the top of her class academically and exhibited the professionalism and attitude of a seasoned veteran. Unfortunately, while her peers were providing the department with regular and routine hours every week, Sarah had family obligations that prevented her from doing so. She would work 4-hours one week, take two weeks off, work 8-hours the next and so on. While she continued to perform at a high level in the classroom, her growth at the bedside slowed.

Finishing at the top of her class, Sarah immediately sat for and passed both the CRT and RRT credentialing exams within two weeks of graduation. Surprising to no one, she also passed the NPS exam as well. Excited to begin her career, Sarah applied for employment at Fairview; and thus, my dilemma began.

Hiring the other three students as full-time employees was a no-brainer. They fit in well with the rest of the department, performed well at the bedside, and exhibited high confidence levels in their ability. Sarah on the other hand, progressed much slower and would frequently solicit reassurances from her co-workers with every decision she made and with each physician encounter. I had concerns as to whether she was ready to make the jump from student to full-time employee.

I solicited the input and advice of my leadership team and of the employees she would frequently work with. Assessments of her ability were consistent across the board. Weighing all of the particulars that ranged from her professionalism, passion and credentials to her clinical performance and confidence, I had made my decision. We would not extend her an offer of employment.

I fretted over the decision for days. Under no circumstances did I want to be the one to share the news with her, but with the information available, the decision had to be made. I took 3 to 4 days to prepare for the conversation. It wasn't easy, and on more than one occasion I tried to convince myself to change my mind. The message was clear however... Sarah would need more experience before stepping into the rigors of respiratory therapy at Fairview Hospital. It would be unfair to her and to the organization to put her into a role she was not prepared for. I was not willing to hire her into a position unless she possessed the tools and was surrounded with the resources necessary to succeed.

We finally had the crucial conversation. Breaking the news to her was not easy. She accepted my decision as anticipated... with dignity and grace. Five years from now, I may look back on her career and ask myself what I was thinking, but as I stand here today, I'm comfortable with the decision. As Sarah moves forward with her career, she'll most certainly do it with Fairview Hospital in her rear view mirror. I wish her luck in her future endeavors. I hope others have the ability to appreciate her professionalism, attitude and determination as I have had for the last year.

If you've made similar painstaking decisions, I would welcome you to share your experiences with the community. If you feel that I'm off my rocker in my decision, I would welcome those comments as well. No one is perfect and I certainly don't pretend to be.

"We never know the worth of water till the well is dry."

- English Proverb

Walk the Walk

2008-06-13T17:56:00Z

On April 29^th, a reader posted a comment to the blog titled A Chain is only as Strong as its Weakest Link. Here is an excerpt from Jim; a Respiratory Care Shift Supervisor.

"I anticipated the day that change could happen, which is the main reason I set out to get involved in management at my organization; I wanted to be able to make a difference! However I am on a regular basis running into road blocks from our so called "team" of other manager's. The staff has quite frequently suggested the need for change but are regularly told "there is nothing that we can do about it". I feel that about three quarters of our staff want to develop a better quality of care for our customers and develop more self efficacy within our department but three quarters of our management team recognize those ideas will create more work on their behalf and in turn they consistently deny those of us willing to take the road less traveled and develop new processes. How are the therapists of today expected to stay excited and goal oriented towards our profession when the weakest links (some of the time) are within our leadership?"

After reading this comment and pondering Jim's dilemma, I'd be willing to bet that there are others out there who share in his frustration and have been down that road before. Let's discuss...

As the old adage goes; "The only thing constant in healthcare is change." As a supervisor or department manager, you must embrace this as fact. Your leadership team is no different than anyone else in your department... yourself included. No one wants to change. As we grow comfortable in our lives, and in the workplace, we do things not necessarily because it's always the right thing to do, but rather because it's what feels comfortable and secure.

While we would all like to believe that people in leadership positions are like robots that can just mindlessly turn on and turn off our emotions and feelings; the plain and simple truth is that we can't. It doesn't exclude us from the fact that leaders must learn to separate personal preference from what is needed for the betterment of the organization... after all, that's what we get paid to do. Leaders are under a microscope. Every decision and action is scrutinized. We ARE held to a higher standard. People are hired into these roles because this is what is expected. If they can't take the heat, they should get out of the kitchen.

With that, Jim, I believe your first order of business should be to sit down with your leadership team and clearly communicate your expectations to them. So long as those expectations are consistent with the mission, vision, and values of your organization; you should be safe. If not, you should probably secure a commitment and sponsorship from your executives and/or medical director first. Communicate the reasoning, and justification for your decisions. Is it evidence-based? Will it enhance the care you provide to the patient? Will it improve employee or patient satisfaction? These should be your key speaking points.

From there, I would communicate with them that you have higher and loftier expectations of them than anyone else in the department; that they must put personal preferences aside for the betterment of the organization and to the patients you serve. You must not be afraid to have this crucial conversation and if substandard performance reviews or performance improvement plans are in order, then that in itself may be the bur under the saddle that will trigger enhanced performance. You must however; provide them with the tools to succeed. Allow them to attend leadership development classes, seminars or other educational offerings. Encourage them to seek out a mentor in your organization who can provide them with an unbiased appreciation for change, leadership and professional growth.

These conversations will not come easy, but simply making the decision to do so will be your biggest hurdle to overcome. Prepare yourself for the conversation, formulate and agenda with key talking points, and maintain focus. Reading Crucial Conversations: Tools for Talking When Stakes are High or Crucial Confrontations is a GREAT place to start your preparation. Follow-up and accountability are equally as important as it is likely they may do what is necessary to appease your taste for change, only to remain complacent. How you respond to that complacency will be key. Will you enable it to take place or will you stand your ground? If your leadership team is truly more interested in their own self interests, they'll do their best to shift responsibility away from themselves and on to the most likely candidates... your staff. Stay true to yourself, your beliefs and to your organization. More difficult decisions may soon follow. You may very well need to ask yourself the question... "Am I surrounding myself with people that are committed to the same level of excellence that I am? If the answer is "no", then I believe you know what it is you need to do.

If you're not in a position to act on some of the recommendations as described above, and are just a frustrated supervisor on an underperforming leadership team, I would encourage you to share your concerns with someone who can make a difference. Be very careful and political in your communications. I won't sugar-coat it... sharing your level of concern and dissatisfaction with your boss (especially if you perceive them to be part of the problem) could cost you your job. It's at that point that you must make the very personal and internalized decision as to whether your organization is the right place for you. Seeking out opportunities in other organizations that share your same passion and commitment may be exactly what is needed. Will you take that leap of faith? Will you walk the walk? Will you embrace change or stay where it's comfortable for you? That is the question.

Following the road less traveled is not easy. It's the trailblazers of our profession that will dictate our future. As an unknown author once said that I think sums it up best; "The scenery never changes if you're never the lead dog". Good luck!

If you've got advice for Jim, I would encourage you to post your thoughts. Share with the community your experiences and how you addressed the situation. Let's learn from one another on how we can make the field of respiratory therapy the best possible profession for our employees and to our patients.

Rome Wasn’t Built in a Day

2008-06-05T14:25:00Z

It's been one of the greatest privileges of my career to serve as a guest lecturer at my alma mater, The Ohio State University. Two years ago, my old program director Herb Douce asked me if I'd like to come back to campus and speak to the graduating senior class on management and leadership. Without thinking twice, I jumped at the opportunity.

To emphasize my point, and to describe the gap between management and leadership, I asked the students to share with me the traits and characteristics of the best manager they've ever worked for. Right on cue, their answers were as predictable as fireworks on the 4^th of July.

"They care about me as an individual," one student replied.

"They're honest and trustworthy," another chimed in.

"They inspire me to work at a level I didn't know I was capable of," said the student sitting in the back row.

"Your answers are typical," I replied. "However, your answers are not synonymous with that of a great manager, but rather of a great leader. Managing the day-to-day operations of a department is the easy part of our job. Ordering equipment, putting out schedules, and doing payroll are all things that anyone with a decent head on their shoulders can do. Being a great leader (as you described above) takes years of practice, dedication and a commitment to your trade. It's one of the hardest things you'll ever do."

I had peaked their interest. Many sat up a little more upright in their chairs, while others nodded in agreement.

"Is it leadership then that is the key ingredient of a high performing department?" one student asked.

I had to ponder the answer of this question before I responded.

"Creating a high performing department is not easy. First, you must have good management. Without someone to provide the resources for others to succeed, they will surely fail.

'You must then have the right people in place. Surround yourself with people who share the same passion, excitement and motivation that you have. This will not come easy. Deciding on who will stay and who must go will be the most difficult and painstaking of decisions you'll ever make.

'Creating a culture that is built around trust, commitment and accountability is a must. An environment in which the employees have a sense of ownership and pride will inspire them to perform at peak levels.

'Finally, you must have strong leadership. You must have a passion for people and for those whom you serve. Be honest, but supportive. Be firm in your destination, but be flexible in how you get there. You must first understand before you can be understood. Be a coach, a cheerleader, a confidante and mentor."

"Is that all?" said the student who asked the question (with just a hint of sarcasm in his voice).

"No one said that Rome was built in a day" I replied.

Manpower Concerns Got You Down? Try Working in Canada

2008-05-28T15:08:00Z

If you listen very carefully, you can hear it in almost any RT break room across the country. Whispers, so deafening you can hear them from the nurse's station on 3 South are the complaints about too much work and not enough people to get the job done. While the manpower issues in our profession will continue to get exponentially worse, we're already smack dab in the middle of this crisis. Hospitals everywhere are feeling the pinch, and managers, for that matter, feel helpless to offer reassurances to their team, knowing that the problem is only going to get worse before it gets better. Boy have we got it bad! Or do we?

Last week I had the wonderful opportunity to speak at the national conference for the Canadian Society for Respiratory Therapists held in Saskatoon, Saskatchewan. Leading up to my travels, I looked forward to learning more about socialized medicine (as is the healthcare model in Canada), as well as to the similarities and differences as to how respiratory care is practiced in the United States and in the "Great White North".

Many things immediately caught my attention. First, I was amazed at the size of the conference. I had visions of the turnouts that are routinely seen at the AARC International Respiratory Congress (in the thousands). At the Canadian conference, however, I was told that registered attendance was about 250. This was of total amazement to me as many state and local meetings that I've attended have drawn larger crowds. It was at this point that I asked my host my first of many questions... "How many respiratory therapists are there in Canada?" I was told there are only about 8,000!

Expounding upon that point, and to my surprise, there was one commonality that I identified among the many conversations I had with Canadian RTs. There were at least ten therapists I spoke with that were the only employed respiratory therapist in their hospital. In addition, I was told that up and to the point that they were hired, their hospital had never employed RTs before. Outside of these glaring differences, I found that there were far more similarities than there were differences in the two healthcare systems and in the way that respiratory is practiced in the two countries.

The American population is estimated to be about 300 million, whereas the Canadian population estimates to be about 30 million. According to the 2005 AARC Human Resource Survey, there are roughly 132,000 RTs in the United States with vacancy rates of almost nine percent. This equates to about one respiratory therapist per 2,100 citizens. In Canada, that ratio is 1:3,750. If the Canadian ratio were identical to ours, they would have a need for an additional 6,300 therapists... almost an 80% increase!

As my time in Saskatoon drew to a close, I was struck by the passion and dedication of the Canadian RTs that were in attendance. It was a very rewarding experience. Arriving back in states just in time to enjoy the Memorial Day weekend, I reflected on my time spent up north. In addition to the appreciation and gratitude I have for the men and women who have given their life for our country, I also have a newfound appreciation for what we as respiratory therapists have in the United States.

What Does the AARC Do for You?

2008-05-19T14:20:00Z

Rhetorical or not, I often hear respiratory therapists ask the question... "Why aren't we treated with the same level of respect that disciplines such as nursing or pharmacy are?" Unfortunately, the answer is like the elephant in the room that no one wants to admit is there. The apathy that plagues our profession is undeniable.

With only thirty percent of all licensed respiratory therapists in the country that belong to our professional organization, it's hard for hospital administrators, physicians, and 3^rd party regulatory agencies to get excited about the respiratory profession when our own members will not.

Some may attempt to justify this masochistic or blue collar approach to our profession. Because of cuts in reimbursement, hospitals around the country are forced to run more efficiently. Labor, wages, and benefits compose about fifty percent of an organization's total operational expenses. As such, the most logical place to make cuts are at the bedside.

For respiratory therapists, many of them - by no choice of their own - have been relegated to the equivalent of a Las Vegas poker dealer. Off they go, leaving their department with unmanageable work loads. Once on the floors, they stand at the nurse's station and "deal" out aerosol and nebulizer treatments with tremendous efficiency. Only those patients who wish to "double-down" and require added attention receive the expertise a respiratory therapist has to offer. Like it or not, this is the life that many of us have been relegated to.

When I ask RTs why they're not a member of their professional organization, there are a myriad of answers.

"The dues are too expensive" says one therapist.

"My membership only pays for two journals that I never get a chance to read" says another.

For most, they just question what it is exactly that the AARC does for them. While the corporate office in Dallas does its best to promote professional accomplishments, the sad matter is that the message just doesn't get out to enough people.

In a recent post, I highlighted one such issue that the AARC has addressed with great vigor. Titled "Administrative Oversight - You Make the Call" I addressed concerns over the Joint Commission's proposed revisions to Standard/EP: NR.01.01.01,EP2. The revision read: "Ancillary services such as pharmacy, physical therapy and respiratory therapy will be required to provide services under the coordination of the nurse executive."

For reasons described in the post, this would be of great concern to respiratory departments everywhere should the proposed revision have been adopted. Because of its potential impact, the AARC drafted a position statement that was sent to the Joint Commission with well documented concerns over the issue. Following receipt of the AARC's communication, the Joint Commission modified the language of the proposed revision to reflect its true intent... "The nurse executive is to coordinate the development of organization-wide patient care programs."

This hallmark accomplishment is exactly why respiratory therapists everywhere should become members of the AARC. The next time a respiratory therapist asks me what the AARC does for them, I will reference this milestone. As Bill Farnham from the University of Tennessee Medical Center said in a recent posting on the AARC Management List Serve: "This is one example of what's RIGHT about AARC. This was perceived as a problem by membership, we talked about it, asked for help, and now it appears to have been fixed. Thanks to ALL who had a part in getting this silly mistake fixed! This is information that needs to be passed on to non-members so they will see that AARC does do good things. A lack of perfection in all that AARC does is not the issue. It's the overall benefit."

I couldn't have said it better Bill!

Canister Your Enthusiasm

2008-05-13T12:47:00Z

In the ever present pursuit of the almighty dollar, hospitals and respiratory therapy departments all around the country are seeking opportunities to improve their bottom line. Feeling as if they're being squeezed of every last penny, hospitals have now come to the realization that reimbursement has been and will continue to fall at a steady rate. Doing more with less has become the mantra in healthcare.

As hospital executives go on their scavenger hunt to find cost savings, one such opportunity has been found in many RT and pharmacy departments. Growing in popularity and in momentum, eliminating metered dose inhaler medication waste through the advent of a common canister approach has proven very effective.

Pharmaceutical companies that insist on packaging their product to deliver 30, or even sometimes 60 doses per canister make it very difficult for hospitals to compete when the average patient may only need the equivalent of 12 - 20 doses per hospital stay. Because of pharmacy regulations that require unique labeling for inpatient and outpatient usage, patients are unable to take unused medications home with them unless relabeled by the pharmacy.

So how does a common canister approach eliminate this problem? In essence, it creates a process in which all of the medication in the canister - right down to the last particle - is completely used. In this scenario, the MDI canister and/or boot are not looked at as the medication delivery device, but rather the spacer (chamber) is. Each patient receives their own unique spacer of which is kept with them during their entire stay. As medication is delivered, the canister is then shared from patient-to-patient. In theory, all infection control concerns are confined to the spacer (of which is kept with the patient) while the unaffected canister (and unused medication) is taken to the next bed space. Is this really safe for the patient?

There are many techniques and processes used with the common canister approach. Some will cleanse the canister between each unique patient encounter, while others perform a "terminal cleanse" at the end of each patient stay and recycle the canister for the next patient to use. Regardless, infection control issues must be addressed.

Many would argue that there is little, if any data which suggests this is an unsafe practice. I would argue just the opposite... there is no peer-reviewed or evidence-based scientific data which would suggest that this is an acceptable and safe practice. While I'm not advocating for or against this process, I would strongly suggest that before your department makes such a decision, that you perform a surveillance study in which you, your infection control coordinator and medical staff are comfortable with and take ownership of the data. Without it, you're taking the risk of exposing patients to hospital acquired infections that will now come without reimbursement.

In a recent survey I conducted of AARC managers who subscribe to the Management List Serve, only 16 of 60 managers who responded claim they utilize the common canister approach. Unfortunately, of those 16, only 2 claimed to have performed a surveillance study at their hospital to validate their decision. One of the 16 respondents even stated that they have no infection control process in place to cleanse the canister, boot or spacer. While there may be an immediate financial improvement operationally, without infection control consideration, the lost revenue from hospital acquired infections could very well prove this decision penny wise, but dollar stupid.

Knowing When to Say When

2008-05-05T13:18:00Z

Three weeks ago, my brother-in-law asked me if I'd like to join him at a Cleveland Cavaliers basketball game.

"I've got an extra ticket and thought you might like to go" he said.

When he offered me the ticket, I almost jumped out of my skin. These weren't ordinary tickets you see... these were floor tickets. As I stuffed my face with overpriced popcorn, $5.00 hotdogs and a $7.00 beer, I was particularly impressed with the halftime festivities offered by the team. On this evening, the Cavs brought in a team of professional "dribblers" that were able to do some of the most creative routines I've ever seen. One act that I fondly remember was that of gentleman who sat on the floor and was able to simultaneously spin a basketball on both toes, both knees, his nose and both index fingers. As I sat there in amazement, I couldn't help but think of this miraculous feat as a metaphorical act of what we all face on a daily basis.

While I can only speak for myself, I'm confident that we've all been there before. It all starts with an innocent request from your boss to take on additional responsibilities. Not wanting to disappoint, you graciously accept their invitation. The next day your medical director has a new request for you as well. The next thing you know there are 15 monitored metrics that you're held accountable to on your management report card. Before you know it, you find yourself in the same position as the halftime performer... trying to simultaneously keep all of the balls spinning before they all come crashing down to the floor.

Managing your time, responsibilities and obligations is no easy matter. When you include your personal life, and commitments to family and friends; work-life balance becomes a full-time job in and of itself. Unfortunately, the culture in healthcare is of finding a way to do more with less. By committing to projects and responsibilities that you don't have time for, you're unable to perform at a high level and unfortunately become quite average (if you're lucky). While some people would argue that that's life in the big city; I would disagree.

Whether it's an added request from your church, additional responsibilities at work, or volunteer hours for the profession, you must know yourself, and your limitations. While your heart may tell you to serve your patients, your work or your family, you're mind must be sharp, rational and balanced. Knowing when to say "no" is as equally as important as knowing when to say "yes". If you don't, your responsibilities will start to pile up like the straw on a camel's back. Before you know it and without forecast, all of those spinning balls will come crashing down around you; leaving yourself to ask the question... "How did I allow this to happen?"

Fortunately for the gentleman at the basketball game, his performance was flawless. Amazed, my brother-in-law looked at me and said, "How did he do that?"

"He knows his limitations" I responded. "What do you think would happen if we asked him to dribble eight-balls instead of seven?"

A chain is only as strong as its weakest link

2008-04-29T13:25:00Z

I often times find that life mimics science. Just as gas follows the path of least resistance during mechanical ventilation, so too do managers when making decisions that impact their department. Whether their decisions are made with selfish intent, or purely without realization, managers will quite often avoid "the path less traveled" for the comfort and reassurance of what comes easiest.

We've all done it. It happens every day... sometimes very innocently. And just as the prologue goes in the movie Armageddon ... "It happened once, and it WILL happen again." It's not that we're vicious or vindictive. The plain and simple truth is that we're quite simply... human. Whether it's avoiding a crucial conversation because of the emotions that are at stake or sneaking out of work an hour or two early on the first 80-degree day of the spring, we all make decisions that will ultimately lead to the greatest amount of generated utility.

While I've been known on an occasion or two to follow the path of least resistance, I recently found myself resisting the urge to do so during a recent restructuring of our staffing model in the intensive care unit. With the intent to elevate the performance of all critical care therapists to model that of our highest performing employee, a change in culture and in responsibilities was needed. The fear for many was that they lacked the skills to function at a higher level (a nurse practitioner or physician assistant if you will). Instead, perhaps it was just the fear of change. Regardless, I had a clear vision in my mind that not just a select few could perform at that level, but rather the entire department.

I was openly questioned by our staff members and supervisors whether or not such a feat was possible. Was I expecting too much from our therapists? Was it an unrealistic pipedream? One thing was for certain, that it was my firm belief that we were going to build a care model in the ICU that would be built to address our highest common denominator... not the lowest. Would it have been easier to simply leave things as they were? After all... no one was complaining about the competence or knowledge of our therapists. Leaving things status quo would have left me (and the staff) with fewer headaches and higher employee satisfaction scores.

As I look back on this decision, I certainly bucked the trend of following the path of least resistance. Just as that old adage holds true in many regards, so to does the one that says your chain is only as strong as your weakest link. How strong our chain will be is yet to be determined. How strong is yours?

The Best Advice Comes When You Least Expect It

2008-04-24T16:21:00Z

As I look back on my career, I shutter to think what could have been. I graduated from the Respiratory Therapy program at The Ohio State University in 1993. I was never much of the academic type and was anxious get on with graduation. I chose the Cleveland Clinic as my employer of choice primarily because it was located less than an hour away from where I grew up. It was my thought that the Cleveland Clinic (and their reputation) would be able to do more for me than I could for it, and that after getting a few years experience under my belt, I'd be able to write my own ticket anywhere I'd want to go... after all, I was a graduate of THE Ohio State University with a bachelor's degree in hand. Who wouldn't want me?

I was never mentored as a new graduate into the field. Maybe it's because logical mentors didn't see the potential in me, or most likely maybe it was because I never sought out a mentor. Regardless, I became what I would classify as an exceptional clinician and critical thinker. Unfortunately, I had a lot to learn about the importance of being a good employee and an ambassador to the profession. Five years after graduation with literally no professional growth, I became somewhat disenchanted with my role and realized that I wanted something more.

It was in 1998 that I expressed interest in and was appointed to the position of clinical coordinator for one of the local respiratory programs located in NE Ohio. Three years later, I applied for my first big opportunity... evening shift supervisor. To no one's surprise but my own, I was not offered the position. I was devastated, but it was the wake-up call I needed to jump start my career. Just a few months later, I applied for and got my first management job at a small inner-city Cleveland hospital. As I look back on what was probably one of the biggest disappointments of my career, I came to the realization that things happen for a reason... that when one door closes, another will open.

In a recent posting titled "Become a Sultan of SWOT", I openly shared my experiences during a rather grueling interview process for a new promotional opportunity I just went through. It's been a couple of weeks since the last interview and I have still not heard anything regarding the position. Rob Capretto, a hero, mentor, friend and confidant recently called to see how things were going with the new position.

"I haven't heard anything" I said. "I hope they're still interested"

"Don't allow anyone to hold you back" he replied. "When you position yourself to advance your career, you cannot wait for an employer to meet your expectations. Don't sell yourself short, and certainly don't wait on them to pursue your dreams."

"You're right" I said. "Everything will work out as it is supposed to... everything happens for a reason."

It was just then that I probably received the greatest advice anyone has ever given me and that I'd like to pass onto you.

"No more - ‘If it's meant to be' mindset. A great leader's mindset is and must always be... ‘If it's meant to be', I'll find a way to make it happen!"

HIPAA… It’s No Laughing Matter

2008-04-22T14:22:00Z

In a recent posting titled "Kids Say the Darndest Things," I described the relationship I have with my son. We're very close, and I spend as much time as I can with him. I coach his baseball team, and whenever we get a chance, we'll play catch in the front yard or shoot some hoops in the driveway.

The love that a parent has for their child is undeniable. They share in their joy when they hit the winning shot, share in their sorrow when a pet dies, and share in their pain when they're sick. The latter was no more evident than this week when my son came into my hospital for a CAT scan. After a two-month illness of unknown origin, his doctor wanted to rule out certain diagnoses.

Later that afternoon after the CAT scan was complete, I received a phone call from the doctor's office.

"Dr. Fine is requesting a consultation with you in his office" his receptionist said.

"What were the test results" I asked.

"I'm not at liberty to share those with you over the phone sir. The doctor will provide you with the test results on Wednesday."

"I need to speak with him now," I replied.

"I'm sorry sir; he's gone from the office for the rest of the day."

At this point, I was in complete panic mode. I know as a healthcare provider that doctors typically don't call you into their office to tell you everything is fine. I knew something was wrong and I had to find out what.

Because the procedure was performed at my hospital, I knew that the dictated radiology results were in the hospital's HIS system... which I had access to. With tears in my eyes, I sat at my computer knowing that the results were only a mouse-click away. I wanted to so badly but knew that inappropriate access to his medical record was against the law, and that if I were caught, I'd be fired. For more than 20-minutes, I sat at my desk, staring at my computer. I was balancing the pros and cons, and asked myself whether the piece of mind would be worth my job. While every bone in my body wanted to access that information, I needed to be strong. I needed to lead by example.

Just then, I realized that I could still gain access to this information; I just needed to go about it through the right channels. I jumped out of my chair and ran to the radiology department instructing them that I would be in need of the CT results for a follow-up doctor visit. After signing a release form, I had a copy of the scan burned onto a DVD, with dictated results that stated everything was normal and findings were negative.

As I returned to my office to phone my wife and share with her the reassuring news; the phone rang. It was Dr. Fine instructing me that he wanted to put my mind at ease to tell me everything was fine and that he only wanted to meet to discuss alternative treatment options.

While I'm no saint, I'm glad I made the decision I did. Rules are in place for a reason. It would have been unlikely that anyone would have found out I accessed the information that day, but the point is, it's against the law. While I had access to that information, I was not authorized to do so.

What would you do in the same situation? As a manager and caregiver, I'd hope you would have made the same decision as I. As a parent, I'm not about to tell you what what's right or wrong.

Become a Sultan of SWOT

2008-04-21T14:05:00Z

One thing my MBA education taught me regarding the success and failure of an organization was the importance of a thorough S.W.O.T. analysis. In simple terms, a S.W.O.T. analysis is nothing more than a 360° evaluation of an organization that scrutinizes an organization's strengths (S), weaknesses (W), opportunities (O), and threats (T). Performed collaboratively with individuals that encompass a wide range of expertise across the organization, the S.W.O.T. analysis is an indicator of how an organization compares to similar organizations in their competitive market-place.

While S.W.O.T. analyses are primarily conducted on organizations, departments, or divisions, the same model can be applied to individuals. Anyone who is professionally driven with lofty career aspirations should perform an internal S.W.O.T. analysis of themselves. Sample questions that one may ask themselves are as follows: 1) What are my greatest strengths or attributes? 2) How do I leverage those strengths for continued growth and development? 3) What are my weaknesses? 4) What risks and limitations will I face if these weaknesses are not addressed? 5) What opportunities are available to me for professional growth and development? 6) What professional opportunities are currently available to me based on my current skill set? 7) What professional threats am I currently exposed to? 8) Do I have any control over eliminating those threats?

Performing a self-analysis that is this raw, open and self-exposing can be a difficult and daunting task for those individuals who lack confidence or with insecurities about themselves. This process is a complete dissection of one's strengths, and weaknesses and only those who are comfortable in their own skin will succeed.

The need for an internal S.W.O.T. analysis can be no more beneficial than during an interview for a new job. Some of the most typical interview questions ask candidates to describe their strengths and weaknesses. I was recently grilled during a series of interviews in which the interviewers placed the focus of the interview on my weaknesses.

"We already know your strengths... they're highlighted on your resume" the interviewer said. "We know about your MBA education and of your contributions to the profession. We want to know about Doug the person... we want to know more about your deficiencies."

Had I not taken the time to perform a thorough S.W.O.T. on myself, I probably would have been extremely uncomfortable in that situation. Instead, I was able to confidently answer those questions. Why? Because I had already asked myself those questions a hundred times before. Better yet, I knew exactly what I needed to do to improve on those weaknesses because I had already laid out a strategy to do so.

There are a plethora of resources on the web that one can access to learn more about the S.W.O.T. analysis... here's a great one to get started. I would also recommend reading Simplified Strategic Plan by Bradford, Duncan, and Tarcy.

As for the job? I've allegedly made it down to the final two candidates. I'll let you know how things go in future postings.