Before I dig into the specifics of evaluation and selection of performance metrics, it’s worthwhile to review how our respiratory care services and procedures were measured during the early decades of our profession and how dramatic a change we’ve witnessed in just the past few years. As ‘inhalation therapy’ evolved into ‘respiratory care’ in the 1970’s, we witnessed an explosion of our profession in terms of desired services. While quality, safety, and patient-centeredness were certainly important components, the ability to generate revenue for our hospital was recognized as the primary force driving this period because reimbursement was directly based on the number and type of services provided within an inpatient stay.
Given this reimbursement schema, the metrics were chosen more to reflect the primacy of charging and service delivery rather than efficiency and clinical efficacy resulting from the delivery of respiratory care procedures. Thus, the metrics utilized by many hospitals during this time included: % breathing treatments done as ordered, % and number of missed treatments (including reason: patient refusal, patient not in room, patient discharged, and RT not available to recheck after initial contact), number of ‘ventilator checks’ (note: this is a term to be replaced by ‘patient ventilator assessment’ or PVA), number of treatments performed by each RT during her shift, charged oxygen hours among others. A new careerist entering our profession in 2019 might look at this and wonder if we really cared about our patient’s response to treatment and whether the breathing treatments were even clinically appropriate or that we were more concerned with ‘getting the charges entered’. I think all would agree that our patients came first, but right on the heels of great patient care was the need to ensure that all services and procedures done were captured so they could be included in the hospital bill. The reason for this history lesson is not to look backward, but rather to reinforce the point that what we measure is related to why we measure and how we are perceived as adding value to our organizations.
This growth in the need for respiratory care services continued throughout the 1980s secondary to a continually aging population, new treatment modalities, and increased capacity for inpatient care. This increased patient need continues through the late 1980s and into the 1990s despite some diminution with the advent of the DRG system (Diagnosis Related Grouping). While far more complicated than this brief description, this system bases reimbursement on the patient acuity and consumption of resources. When the physician documents the reason that the patient was admitted, it created reimbursement associated with that diagnosis. In my experience, this was a pivotal point in the transition of ‘do more and increase reimbursement’ to ‘do what is necessary because reimbursement is fixed’. As such, our respiratory care services, not unlike other clinical departments, such as imaging and laboratory services, began the transition to using metrics that matched the new imperatives for hospital operation-productivity.
How does a profession that was birthed in a period of growth, expansion, and valued as a significant revenue center for the hospital transition to a new system? The answer lies in understanding the forces shaping the new and far more complex health care delivery and reimbursement system, primarily for hospitals, and what we must do to document the need for the clinical staff required to support this new system.
To get a sense of what metrics were being used by RT leaders, I recently conducted a survey by enlisting ~ 150 RT department heads representing various hospital sizes, for-profit and not-for-profit, and community hospitals and academic medical centers. The survey wasn’t meant to be statistically valid, but the great response rate told me that this issue is one of the most important ones that RT leaders believe are impacting their departments. I asked RT department heads to answer two questions with regard to performance metrics:
1) list those productivity metrics that you are required to utilize by executive leadership in order to measure your RT clinical staff productivity and
2) list the metric(s) that you believe is/are the best metric to accurately measure your RT clinical staff productivity and, as a result, determine the required clinical FTEs.
The list included the following:
- billed procedures,
- total charges,
- CPT-coded procedures,
- Average Daily Census (ADC),
- Ambulatory Payment Classifications (APCs),
- Case Mix Index-adjusted discharges,
- internally derived procedure time standards, and
- the AARC Uniform Reporting Manual (URM).
The responses to the first question listed billed procedures, CPT-coded procedures, and Case Mix Index-adjusted discharges as the top three in that order. The responses to the second question revealed that RT leaders believe in time-based standards as the most appropriate metric, because AARC URM was the most numerous response, with internally derived procedure time standards coming in second place. What many respondents indicated was that they use time standards, whether AARC URM or internally derived time standards, and convert them to a Relative Value Units (RVU) system (e.g. 15 minutes = 1 RVU) for use in patient care distribution at report as well as tracking procedural time per patient unit, shift, day etc. Of note is that a significant number of respondents indicated that while they are required to measure productivity by executive choice, they run the AARC URM in the background.
What’s interesting is that the only valid metric is one based on assignment of time to each procedure. For those unaware of the AARC URM, I’ll provide an overview of the tool. The majority of our services/procedures provided by RTs are incorporated in the URM and arrayed by adult, pediatric, and neonatal procedural times. What we recognize is that there is great variation between RT departments. Not all procedures are done by all departments, and not all procedures are captured in the AARC URM. For those services not included in the URM, the RT director can measure and assign standard times. For those services that have highly variable completion times (e.g. rapid response, code blue, ventilated patient transport to imaging etc.), I suggest counting time by capturing these in 15-minute time blocks (e.g. 1 hour patient transport would be documented by 4 15-minute segments).
The AARC recognized many years ago that our practices and staffing are not universally accepted by all organizations. While we as RT leaders would expect that our executive leaders would accept our use of this system as opposed to systems and metrics not validated, the AARC created an AARC Position Statement, entitled ‘Best Practices in Respiratory Care Productivity and Staffing’  and an AARC White Paper, entitled ‘Best Practices in Respiratory Care Productivity and Staffing’  to address how to properly measure productivity in order to determine the required clinical RT FTEs. Both documents can be found on the AARC website www.aarc.org.
To summarize the AARC position on staffing, it is important that providing safe respiratory care is largely dependent on providing adequate numbers of competent RTs. It continues to be a foundational principle that the use of inappropriate metrics can result in inadequate numbers of RTs which may place patients at risk for unsafe care and delayed/missed essential respiratory care services. Readers are encouraged to access both of these documents and engage all key stakeholders to ensure both understanding as well as adoption of the proper metric based on validate procedural times.
Our profession and our practices have moved from a historical period during which ‘more is better’ to one that recognizes the value of our services and measurement of productivity based upon nationally validated procedural times. It is absolutely critical that RT leaders at all levels educate and engage all stakeholders to understand and adopt clinical staffing FTEs based upon the national standard. Use of non-validated metrics that don’t account for the differences in intensity of services should be exposed and relegated to the history bin of productivity. Using a validated system is not about focusing on the RTs, but rather on establishing safe and effective staffing levels to ensure high quality, cost-effective, and patient-centric care.
Meet The Expert
Garry W. Kauffman, RRT, FAARC, MPA, FACHE
Garry W. Kauffman, RRT, FAARC, MPA, FACHE is a registered respiratory therapist with over 40 years of experience. Garry was selected for the AARC Fellow (FAARC) based upon his contributions to the profession at the national level.
Garry received his MPA from The Pennsylvania State University, and achieved the distinction of board certification in health care (FACHE) from the American College of Healthcare Executives.
Beginning his career as a bedside clinician, Garry has served in clinical, educational, and administrative roles in a variety of healthcare organizations and venues from short-term acute carehospitals, physician practice, ambulatory services, and long-term acute care hospitals. He formedKauffman Consulting, LLC and is the manager of this health care consulting company.
Garry is recognized for numerous journal publications, author/co-author of respiratory care textbook chapters, and as a frequent speaker at the state and national level. Garry has served his profession at the district, state, and national level where he has served in the AARC House of Delegates, AARC Board of Directors, and AARC President. Garry has served his profession in various volunteer roles as the AARC Chartered Affiliate Consultant; AARC Benchmarking Committee; AARC Advanced Practice RT Task Force; AARC Strategic Planning Committee, Respiratory Care author/reviewer; AARCTimes author/reviewer, AARC Uniform Reporting Manual, and ARCF Education Recognition Award Judge, among others.
Garry’s focus continues to be on communicating the value of respiratory care services delivered by Respiratory Therapists by connecting the science of respiratory care, documenting outcomes secondary to our services, and communicating our value to key stakeholders in the health care system.
Garry Kaufmann is a paid consultant of Vapotherm.
 American Association for Respiratory Care Statement: Best Practices in Respiratory Care Productivity and Staffing’, published 07/12 and revised 07/15.
 American Association for Respiratory Care White Paper: Best Practices in Respiratory Care Productivity and Staffing, published 11/12.