Goals and Strategy
Every week, I try to read at least one book from the business section of Amazon.com. To be sure, many of them are rubbish. The really great ones change the way I think – Blink, for example, by Malcolm Gladwell. This week’s book is Good Strategy Bad Strategy by Richard Rumelt. This book is neither rubbish nor changes the way I think but it articulates many of my own feelings about both business and nursing.
Mr. Rumelt should have talked to nurses before he wrote his book. Good nurses are excellent at planning strategy except we call it care planning. On the business side of things, we often confuse strategy with goals. Or we think a mission statement or ‘shared vision’ is the answer to growing business. We have entire strategic planning events where a grocery list of goals is put forth. But in business, we rarely come up with good strategy.
Strategy is the part we gloss over. Strategy is the part where we roll up our sleeves and do things to accomplish the goal. A good strategy takes into account the obvious hurdles. A bad strategy is easily recognized by buzzwords and cliché’s. Nurses do not write, “Dress wound appropriately using innovative and imaginative methodologies and the latest technology to outshine the competition.” I would love to see a surveyor go after that order. They simply determine how to best treat the wound. In other words, they write about specific orders.
The greatest barrier I have found in strategic planning is an agency is fear. Great strategy means making focused decisions and setting priorities for the organization. It is not a democracy. There may be other needs in the agency that are not being met while resources are focused on another area. The ‘shared vision’ may not be universally shared when attention is focused on only one part of the agency.
However, like all businesses health care sells widgets. Our widget is patient care. A blog readers states that documentation is akin to a receipt for payment. So, the first question you should ask is whether or not your clinician skills are where they need to be and if the documentation supports payment. Only when the answer to that question is a confident, ‘Yes!’ can you address other areas in the agency. So, most home health industry leaders agree that clinical care and subsequent documentation is critical.
But, what is the strategy? I have seen many that don’t work. Reading notes as they come through the door and writing deficiency reports is not the answer. The value of note outside of the context of a chart cannot be determined. Scolding the nurses as though they were two year olds is not good leadership. I didn’t read that in a book. It is just a gut feeling. Electronic programs such as Episode Master are great tools but like a hammer, it is limited in scope. You cannot build an entire building with only a hammer as a tool and you cannot build clinical excellence with Episode Master. So really. What is your strategy? What are the specific steps that need to be taken to improve your clinical skills and documentation?
Assuming documentation is your Achilles’ Heel, think of all of the other problems improving documentation can solve. Billing is done timelier and more efficient. Marketing is easier when good documentation allows for communication with referral sources. It is easier to assess skills of clinicians when they are documenting appropriately. Surveys are conducted by surveyors instead of terrorists. Money earned is money kept. The list can go on forever.
So whether it is documentation or another area in your agency that is jeopardizing your future, be strategic about it. Find the problem. Diagnose the cause of it. Get all the information you can and then make the hard decisions. Limit your focus to what is ailing you.
You cannot fix everything wrong with your agency in one fell swoop and yet, if you have a bad survey that is exactly what will be expected of you.
If you are feeling creative today, post a comment about what your strategy is for the future. Or, email me with your comments.
This is very interesting again! Goals and Strategies: Like you stated, You cannot fix everything wrong with your agency in one fell swoop but after a bad survey it appears that all the strategies and goals thinkable will be initiated to miminize sanction. With that said, I develop my own strategies and goals for my team but it is a constant struggle because it apperars that although we hire professional nurse, therapist…. they just don’t get it! One of my strategies is to provide my team with the resources to submit electronic documentation that supports the requirement of Medicare, the goal being this will lead to an increase knowledge base and minimize errors. In most case the information I provide would do this if it was excuted by the clinicians all the time. Because there is so much non compliance from staff, strategies and goals are only as good as the paper they are written on because if staff won’t buy in, it’s dead before it has its chance to work and the end result is tags which only the owners seem to care about, because the people who could make a difference don’t care or won’t listen and are the biggest offenders.
I believe one of the strategy the owner’s of my agency had was to purchase an electronic system that would be more efficent and require less time for the clinician, goal being increase revenue and compliance. After one complete year on this system, if i were a betting person ,I would say their strategies and goals will have to be revisited real soon! So I will read again the above information above and begin again to diagnosis the cause of the non compliance.
I am a total and complete geek and think everything should be automated. I love electronic documentation but the benefits of electronic documentation are not miraculous. You cannot take an apathetic nurse and turn her into a compliant, highly skilled clinician by giving her a computer. I like your idea of discovering why the clinician’s just don’t get it better. Then you can address that issue. Have you looked at your hiring process? Does your agency enjoy a good reputation in town?
You brought up a point that I routinely bring up when I do quality assurance work for agencies. We must recognize and be okay with failure. Yes I hate to fail. I have no appetite for it. I don’t know anyone who does. BUT, when the best and brightest in your agency put together a plan to address compliance and documentation and it isn’t working, the worst thing you can do is to ignore the failure. And because we get so emotionally invested in our strategies, we are convinced that it is the implementation of said plan. So we add another layer. And we get someone else to monitor. And we write reports, draw fish bone diagrams, build grafts, until the whole project is so complicated nobody gets anything done.
Here’s what you tell your bosses – nicely. You realize that numerous studies have tied the success of a health care facility to the sophistication of its technology and you fully support their decision to go electronic. However, it hasn’t solved all problems and that you are specifically having to deal with non-compliance from professional people. Be diplomatic. Ask them for advice. Then after they tell you what they think, present your plan. Remember, there are egos involved. Your message is that the computer is great but it doesn’t do much for the overall knowledge base and compliance of the staff. And here is what you would like to do………………………………
Having said that, I want to point out one thing to you that maybe not as sweet as my usual self. When you speak of your constant struggle, you say it is because, ‘they just don’t get it!’ This blog is a place to blow off steam. I do it all the time and frankly I think it has saved the life of more than one nurse I felt like shooting. My new weapon is a taser so I can shoot nurses repeatedly. However, it is important that we remember that nurses and therapists deserve our respect. One of my hardest conversations ever with a client was when I showed him a report with abysmal results. He looked at me and asked who was supposed to teach the nurses about PPS. I thought about it for a minute. Finally, I said, ‘me’. Of course, there were other people involved because this was an out of town client but the information originated from me. There may have been some poor decisions made onsite outside of my control but they were exactly that – outside of my control. And so the next week, I began a whole new PPS education campaign with stellar results.
There is a moral in sharing that humiliating story with you but a client just walked in. See if you can figure it out. Damn, sometimes I think I pay more for my education than the average Harvard grad but the installments are made in dignity)
KISS …. keep it simple stupid….
A STRATEGY TO ADDRESS ANY ACUTE PROBLEM IN AN AGENCY MAKES SENSE. LONG TERM SURVIVAL OF AN AGENCY IS DIRECTLY RELATED TO ITS ABILITY TO BE DYNAMIC AND FLEXIBLE WITHOUT BREAKING. WE DO TAKE CARE OF THE NATIONS ELDERLY, BUT WE DO SO IN AN ENVIRONMENT THAT IS HIGHLY REGULATED, AND REGULATED IN A SYSTEM THAT CAN CHANGE AT ANY TIME , OUR REGULATIONS ARE INTERPRETTED VERY DIFFERENTLY REGION TO REGION. IT SEEMS AS THOUGH THE EASY PART OF WHAT WE DO IS NOW THE ACTUAL PATIENT CARE, AND THE DIFFICULT PART OF WHAT WE DO IS TO PROVIDE THE CARE IN COMPLIANCE WITH ALL OF THE REGULATORY AGENCIES INVOLVED.
I agree with both comments, however regulations are regulations and we must follow the rules. Now don’t get me wrong, I’m not 100% on everything I do as a Supervisor but I do recognize from all the reading that I do that Medicare is serious about their expections from Home Care Agency’s. So for me ACCOUNTABILITY is the key. Once you have aquired the knowledge of how documentation, Homebound status, F2F all need to work then WHY is there so much non compliance. I like my job, so I learn as much as I can, retain what I learn and ever=n pass the information on to my team. Writing orders, Care plans are apart of the job but what i am seeing at my agency is a lack of accountability from the clinician and the power that be are only looking at the bottom line now and not how it will be affected in the long run. Once I started reading Haydel, I really began to understand that the issue I see are not just at my agency. I agree with the above statement “long term survival …..I only wish everyone would see it that way.