In talking with Respiratory Therapy leaders about productivity for more than a few years, their responses about their authority range from ‘none’ to ‘done’. Those replying that they have no authority indicate that administration has chosen the metric to use for each department and there is no possibility of replacing this. For those replying ‘done’, they say that they were successful because they treated this as a business imperative and created the proposal in a way that aligns with how executives think.
It’s not enough to schedule a single meeting to plead your case to replace the current metric with ‘your metric’. Trust me on this, because I’ve done it and failed each time because I didn’t approach this in a way that executives think. As an RT leader, you have to demonstrate the validity of the time standard as the only metric to use, make the change initiative a priority, create an educational plan, and implement your change initiative by delivering it in a business plan format familiar to executives.
My focus in this blog is to take ‘none’ to ‘done’ by creating a plan to ensure your success.
Business plans are more complex than this, but I’ll suggest that we can achieve success by addressing these key elements of any change initiative:
- Value proposition
You are encouraged to expand this list for your organization as appropriate.
To get the attention of any audience, the title should be concise, clear, and focused. This is what gets the executive’s attention and is the lead-in to why this is important to the organization. As I’ve noted in other blogs, I believe we’ll be far more successful if we show the value to the organization rather than focusing just on the RT department. This may seem counterintuitive, but leaders are more influenced by factors that impact them and that affect the organization as a whole rather than at the front-line. For example: “Implementing a mobility program for ventilated patients”
We could call this the ‘purpose’, but I’ll suggest that we use the verbiage that executives use. When you use ‘Value Proposition’, you’ll not only be speaking their language, but they will recognize that you know the right terms to use. In short, words matter. I suggest that the value proposition be 10 words or less. If we stay within this word count, we won’t be tempted to include goals, metrics, and other elements. Additionally, we’re still in the phase of grabbing the attention of the executive and we don’t want to get too far in the weeds, for fear we’ll lose her attention.
The value proposition can be written at several levels (i.e. organization, department, shift etc.), but I’ll suggest that we write this at the organizational level and here’s why. If we approach this only at the department level, we may be met with suspicion that this is only about saving our clinical positions by using a ‘fox watching the chickens’ methodology. What’s important to communicate is that this isn’t just about ‘saving positions’, but is rather getting to the truth about how many FTEs we need, how we flex to meet changing patient demand, how we cover the ED, NICU, rapid responses, code blues, and the myriad of value-added services we provide. If we transition from talking about how many staff we need to that required to provide safe and effective staffing for the patients we serve, we’ll be shifting the focus from our needs to those of our patients. For example, “Implementing a mobility program for ventilated patients to reduce time on the ventilator, ICU length of stay, and costs.
The best references are contained in the American Association for Respiratory Care Position Statement: Best Practices in Respiratory Care Productivity and Staffing 2012 . Your executives and other key stakeholders may not recognize the AARC, but they will take notice of the Medicare Hospital Conditions of Participation and note that you are on top of these regulations.
Medicare Hospital Conditions of Participation state that there must be adequate numbers of respiratory therapists, and other personnel who meet the qualifications specified by the medical staff, consistent with state law. They further require hospitals that provide respiratory care services to meet the needs of their patients in accordance with acceptable standards of practice, which among others, are based on recommendations promoted by nationally recognized professional organizations (e.g., American Association for Respiratory Care, American Medical Association, American Thoracic Society, etc.).” 
‘Words matter’ and this gets them thinking in the right direction, but as you’ll notice, this doesn’t specifically indicate how many FTEs are required in your department. What you’ll want to have handy is the AARC URM  to illustrate that the value proposition is based on validated methodology and not just something to keep your current staff.
At this point, you may be wondering why I’m spending so much time on the value proposition, which I already said should be short and sweet. It’s because the acceptance of your value proposition is the ‘go/no–go’ step. The value proposition doesn’t change for each stakeholder, but it must address the “What’s In It For Me” for each stakeholder, which I’ll address next.
You’ll notice that I didn’t use the singular ‘stakeholder’, whom you might see as your immediate supervisor. In every case, there are multiple stakeholders and they sit in leadership and supportive roles through your organization. While the specific individuals/titles are unique to each organization, I’ll address those that you should always include in your plan: Medical Leadership, Executive Leadership, Quality Assurance, and Performance Improvement
With regard to physicians, it absolutely must start with your RT medical director. If she’s informed, engaged, and committed to supporting you, it’s the best chance you’ve got to succeed. Conversely, if she’s not on board, it will be quickly noticed by other stakeholders and the chances for success disappear in most cases. Thus, make sure that your RT medical director understands the current metric (e.g. procedures, CMI-adjusted discharges, billables etc.) and why the metric(s) are not valid. Then, explain why validated time standards are the only appropriate metric to gauge clinical FTE requirements. What I’ve found is that physicians are highly educated scientists and they will support us when we approach this as they approach their clinical responsibilities.
Once your RT medical director is engaged, look at other physicians that may be supportive of your proposal. Showing them the science behind time standards and that you’ll staff accordingly, should serve as a means of assuring them that you’ll have the required clinical RTs to provide the care that they order directly or via your patient-focused respiratory care protocols. These would include pulmonologists, intensivists, hospitalists, and anesthesiologists.
When we use the term ‘C-Suite’, we tend to think of the CEO, COO, VP Operations etc. I’ll suggest that we expand this to also include the CNO, CMO, CIO, Compliance Officer, CFO, and perhaps even the Chief Experience Officer (CXO). For each of these, there is a WIIFM (What’s in it for me?). For the CFO, she’ll be thinking about whether this new system will increase labor costs. The CMO likely will be thinking about how the medical staff will weigh in on the proposal. The Compliance Officer will be assessing whether this new productivity system will impact regulatory issues. The CIO will be thinking about how this new system will be integrated with the EMR. I have always felt that the CNO is our closest ally, in that she remembers what it was like to provide bedside care and she knows at her executive level what this might mean to operations. If your organization has a CXO, she may be engaged because your new staffing model based on time standards may provide increased patient satisfaction.
Depending on their role within your organization, Quality Assurance and Performance Improvement professionals should be addressed in your proposal. For QA folks, they’ll want to ensure that any changes in staffing secondary to adoption of your new system will not impact the delivery of high quality care. The American Association for Respiratory Care Position Statement: Best Practices in Respiratory Care Productivity and Staffing 2012 should be part of your discussion with the QA professionals. The Performance Improvement professionals play a critical role, in that they not only are charged with assisting with changes to improve performance, but have the knowledge, skills, and technology that can be of great help to you.
While I’ve provided some brief ideas on what might be each stakeholder’s WIIFM, you’ll want to document for each of these stakeholders and create focused education and messaging so that you can engage them to support your proposal.
As with any business proposal, it’s critical that we clearly communicate how performance will be measured with this new system. Additionally, I’ve found it useful to continue to run the current system (e.g. FTEs based on procedures, billables, census etc.) and do a ‘side by side’ comparison over time. Many budget directors will want to do this anyway, so it’s a great opportunity to illustrate the value of a productivity system based on valid metrics as the best system to measure productivity. Not only will this show the value of a productivity system based on validated time standards, but it can serve as a means of demonstrating that counting nebulizer treatments and ventilators the same is easy but not accurate (i.e. ‘1 doesn’t equal 1’).
After Switching to a New Productivity System—What Then?
Once you gotten approval to transition to the new productivity system, the process has just begun. It will be important for you to ensure that the new process is accurately and completely capturing all of your clinical services, both those that are billable as well as those value-added services that aren’t billable. Additionally, for those highly time-variable procedures (e.g. rapid response, ICU rounds, code blue, transports, and others) that aren’t captured as a standard time, it is critically important to accurately count these (e.g. in 15-minute time segments) within your EMR. For many RT departments, the billable procedures may only account for 30-50% of total procedural time. Thus, attention to accurate and complete capture is the most critical part of this process. The worst case scenario would be for the stakeholders to have approved your new system and only later to be told that “it’s not capturing all of our procedures and that’s why our productivity is below target”.
With a validated productivity system fully established, you’ll want to communicate your productivity as per your hospital policy (e.g. monthly productivity report). I’ll suggest that you retain a core group of stakeholders to assist you in your ongoing and systematic review of the new system and to engage them to support changes as necessary over time.
Comparing Your Performance
While I’ve spent most of this blog talking about internal use of productivity, I want to address the issue of benchmarking. Benchmarking is typically referred to as comparing performance between ‘like’ organizations, but can also be used to compare performance within RT departments in a hospital system. With regard to defining ‘like’ organizations, RT leaders do have some ability to ‘normalize’ their department in various ways so that the comparison between departments is valid. However, if a non-valid productivity metric is used (i.e. anything but time-based metrics), the normalization is either compromised or invalid. Thus, this reinforces our utilization of time-based procedures rather than the other metrics because one can better compare a 500 bed hospital RT department to a 100 bed RT department’s productivity is the formula is procedural time/RT worked clinical time. What will be essential for the RT leader to do is to establish ‘core staffing levels’ (i.e. minimum number of RTs per shift to provide safe care) and ‘fixed staff’ (e.g. PFT, HBO, Pulmonary Rehabilitation, ED, NICU) that are required to staff a unit/functional area regardless of the patient volume. Diving further into this is probably the domain of another blog, but for this blog, I’ll suggest documenting fixed administrative positions (e.g. Director, Manager, Administrative Assistant), fixed clinical positions (e.g. PFT, Pulmonary Rehabilitation, ED, NICU), positions with shared administrative and clinical functions (e.g. Team Leader is 80% clinical and 20% administrative), and the variable clinical staff. Acknowledging and documenting this information will provide the RT leader with not only the best system to use for internal productivity but also permit better comparisons when benchmarking with other RT departments in other hospitals/systems as well as within their health system.
- Getting approval for a new productivity system requires the RT leader to approach this as a business imperative.
- Creating a value proposition that addresses the value to the RT department AND the organization is essential.
- Identifying and educating all stakeholders is critical to engaging them and getting their support.
- Communicating the process and outcomes and making adjustments to optimize the system on a regular and systematic basis is key.
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 Position Statement: Best Practices in Respiratory Care Productivity and Staffing 2012. http://www.aarc.org/resources/position_statements/productivity_and_staffing.html
 42 C.F.R. § 482.57 Condition of Participation: Respiratory Care Services.
 AARC Uniform Reporting Manual https://www.aarc.org/resources/tools-software/standards-development/