The human resources department is an unlikely ally for a successful ICD-10 implementation, and its aftermath.
Billing and procedure coding aren't exactly HR's domain, but there are many ways in which the HR team, working with hospital administration, can help guide an organization through the ICD-implementation on October 1, says Lynne Thomas Gordon, CEO of the American Health Information Management Association (AHIMA).
HR can help by ensuring adherence to policies that will make the implementation successful, by finding solutions that will allow workers to focus more time and effort on the transition, and by making the process as pleasant as possible.
"Leading up to implementation, IT staff, coders, and HIM won't be able to take vacations and will be spending long hours at work," says Melanie Endicott, senior director of HIM practice excellence at AHIMA. "There could be some burnout and low morale among employees. It's up to HR and administration to figure out how to pump people up."
1. Be Onsite; Interact with Staff The most important thing both administration and HR can do is to be present during the ICD-10 implementation. "Being visible at this time is very important, especially as we start the final countdown to October 1," says Gordon.
Try to have as much interaction as possible with the teams impacted by the implementation. Have lunch with the coders or coffee with physicians and ask how they feel about the training they've received so far. Try to arrange a special visit with the IT department to address their concerns. Give everyone an opportunity to raise the flag if they have any questions or worries.
This is especially important as the ICD-10 date nears and many workers find themselves putting in extra time. Make an effort to visit the teams pulling the longest shifts; if IT is burning the midnight oil, for example, come down and see them with a special delivery of coffee and donuts.
Speaking of being present, Gordon also suggests placing an organization-wide moratorium on vacations from the first week of September through shortly after implementation. "At this point, it's all hands on deck. Everyone needs to be in the hospital." Just remember that this means you and the executive team, too, so wait until November to take that trip to the Bahamas.
2. Be Flexible; Make Things Easier Members of some teams are going to work many hours over the next few weeks. Anything you can do to make any area of their lives easier will be appreciated.
Consider allowing teams to work from home or take advantage of flex time, says Devin Jopp, president and CEO of the Workgroup for Electronic Data Interchange (WEDI), a non-profit health IT organization. "With all the extra hours employees will be putting in, it's probably a good idea to have opportunities for some flexibility."
Endicott suggests hiring on temporary coders for a couple months. "It might not be a bad idea, if want to maintain productivity… it can help get you over the hump."
If employees are under deadlines and working hard, they might not have time to run out for lunch or dinner. Have catered meals sent to them in their departments, especially if they're working late.
Melanie Endicott
Another idea is to offer employees services that run errands such as picking up dry cleaning or offering gift certificates for housekeeping or meal delivery services—anything that will take a responsibility—even a non-work related one—off their crowded plates.
3. Show the Organization's Appreciation Endicott suggests sending out an email a few days before launch, to the entire organization, calling out members of the team who have proven indispensable or who have gone out of their way to help with the implementation.
"There should definitely be some show of appreciation," says Gordon, suggesting that "administrators rove around and visit as many departments involved as possible," showing their gratitude for all the hard work that has gone in to the implementation. Handwritten thank you notes to key players are an excellent touch.
Also Gordon suggests that the HR team to bring around an ice cream cart, lunch, or pizza on October 1—or some other treat workers can enjoy while putting out potential ICD-10-related fires.
Endicott suggests throwing an organization-wide party, banquet, or barbeque two or three weeks after the implementation is completed. "Use it as an opportunity to reward and recognize those who put in extra time and effort," she says.
Jopp has a more pragmatic approach. "Cash bonuses are always nice." Other ways he suggests recognizing employee contributions include plaques of appreciation, awards and gift certificates to local shops and eateries.
The most common theme here is recognition. Be sure to recognize the hard work employees put in to the implementation and recognize those who go above and beyond. And recognize that this is not just business as usual; many employees will be giving up vacations, time with their families or other pursuits to make this implementation happen. But the homestretch has started, and this won't last forever.
"It's important to remind everyone that we're going to get through this. It's going to be ok," says Gordon.
Regina Holliday, an advocate for data transparency and patients' rights, talks about open data as a means to better outcomes, and describes her biggest accomplishment so far.
Inspired by the death of her husband, artist Regina Holliday is a fierce advocate for patient rights, meaningful use of electronic health records, and for giving patients control over their personal health data. A painter and muralist, she founded the Walking Gallery of Healthcare, which focuses on the patient experience and data transparency in the American healthcare system.
Holliday spoke recently with HealthLeaders Media about her work and about her vision for the future of data transparency. This interview has been edited for length and clarity.
HealthLeaders Media: What have you been working on lately with regard to regulation and policy?
Regina Holliday
Regina Holliday: Meaningful Use (MU) stage two was in its comment period last spring. I and other advocates I know were outraged when CMS watered down legislation regarding the portal. [CMS] had originally stated [as a requirement] that in the 90-day reporting period, at least 5% of the patient population [would have] had to have viewed the portal and [CMS] wanted to change [from 5%] to one patient. Literally one. If one person in the entire care setting looked at their portal, it would fulfill the conditions.
I did a paint protest in response in front of Health and Human Services' offices. We painted [canvasses and jackets] in front of the building, all with the theme of data access. The aim of our efforts was to try to get people to comment on the legislation, and also to encourage those who make the final decisions consider the patient perspective. And, while security came out several times, they eventually realized we were harmless. We managed to not get kicked off the grounds.
In stage three of MU, we are pushing for more real-time data access, with the thresholds as high as they initially were going to be, but also to get more information into the portals. The deadline for comments was in late May. That's what I've been working on so far as legislation.
I'm also part of technical advisory panels where I represent patients' voices. Those panels are focused on hospice and acute care. That's not legislation, per se, but I'm working with organizations to prototype ways of care so they can be utilized as a model by folks like CMS.
HLM: What can data transparency do for improved patient outcomes?
Holliday: Right now, patients have very little access to their data, even with MU. You get discharge summaries, labs, you get a list of meds prescribed—that's just not very much information. With the Open Notes project, you, doctors, and nurses would be able to communicate through a completely open medical record.
For example, we never get to see if there's an error in our health records. If medical records were open, we could see the full picture of care—and we could amend it to clear up errors.
If you don't have access to your data, you just have verbal information given to you during your visit. A lot of people's ability to recall is not so good, and often they don't understand many of the words used in a healthcare setting. Most of us are brought up to avoid appearing stupid, so we'll smile and nod as the doctor or nurse talks to us, even if we don't understand what they're saying. And without access to the written record, we never will.
There are literacy concerns, but even those with a low literacy level very frequently have someone in their life—it could be a child, a spouse, a neighbor—that does have a high literacy level, and will help them to understand what the paperwork says—but they have to be able to access it.
Right now, it's very, very hard for patients to get access to this information, so it's difficult for them to make intelligent decisions about the future of their care.
HLM: How do you envision this greater transparency manifesting itself?
Holliday: I'm a big proponent of the Blue Button. I think it's a good idea to have a complete data download available to patients.
For patients with multiple providers, there might be as many as nine portals they need to visit to get all of their health information. No one has the big picture of what's going on in these patients' health lives. Having the patient be the endpoint of the data dump and their ability to transport it to something else which can crunch it all together is a good goal.
There's never been big data in healthcare before. All the data has been closeted and siloed. There's never been enough access to this data to make it worth it, but that's changing. Patients being able to get to that data and put it into an interface that makes sense, is user friendly, and has a complete picture of payers has wonderful potential to improve healthcare for virtually everyone.
I think the key technologies for giving patients power over their data include, of course, mobile tech and mobile-enabled devices. We have to make sure everything works on mobile interfaces. Many medical organizations are still more focused on desktop, but a lot of people don't have desktops computers anymore, and many users are going straight to mobile.
User experience design will be a big component of this. Many sites and portals are still very clunky, very 1990s. We've got to get into the current age and make it much more user-friendly.
I think we'll completely skip unique identifiers that are number-based in this country and go straight to visual [or] facial identification.
HLM: What would you consider to be your greatest accomplishment in advocacy so far?
Holliday: That would be MU stage one. When I first started advocating for data access, I didn't know what HITECH was—I didn't even know how to spell it. Twelve days after my husband died, I went to a federal meeting called CONNECT 2009.
I got to ask a question, which was about patient data access in electronic medical records. The speaker responded by telling me that patient data access was not the point of this legislation—the point was for doctors to talk to doctors and facilities to talk to facilities. I was floored.
A man named Fred Trotter came up to me and told me about the HITECH legislation, which he'd read front to back. There was a sentence in that thing that, if not cut, would achieve patient data access. So, we were trying to push forward patient data access as part of MU based on a little tiny clause within HITECH. And we did it!
On July 13, 2010, I was invited to be on stage at HHS for the announcement of MU to represent the patient voice. That day was the day the most powerful, because I felt it meant that the patient was truly being accepted at the table—and it's why I still fight. Because to be truly meaningful, patients have to be part of the voice.
Coding experts from the American Health Information Management Association and the Workgroup for Electronic Data Interchange count down the steps healthcare organizations should be taking in the final weeks before implementation.
October 1st, the day ICD-10 codes must be implemented, is just weeks away. As summer wanes, anyone hoping for another reprieve from the Centers for Medicare & Medicaid Services is almost certainly about to be disappointed.
There's no time to waste. Follow the guidelines below for the best chance of a smooth implementation.
Melanie Endicott
T Minus 5 Weeks
"By now, the IT department should have identified every system that used ICD-9 [-CM] codes and validated that [the systems] are ready," says Melanie Endicott, senior director of HIM practice excellence at AHIMA.
She also recommends reviewing contracts with third-party payers at this time. "Most private insurance companies have their own version of diagnosis-related groups."
"Make sure they have materials ready that they will need to consult on game day, says Devin Jopp, president and CEO of the Workgroup for Electronic Data Interchange (WEDI), a non-profit health IT organization. "[Insurers] should have received training by now and should know the top 10 diagnosis codes [they will use]."
"Now is the time to make sure system upgrades have gone through," says Lynne Thomas Gordon, CEO of the American Health Information Management Association (AHIMA). It's also a good time for the finance team to test claim submissions with carriers and check that the facility has "saved up some cash just in case."
Human resources should also consider bringing on a few temporary coders to help keep the coding team on track and avoid productivity loss, Endicott says.
Case managers and finance should be ensuring preauthorizations for procedures that will be performed on or after October 1 are completed in ICD-10.
Some team members will already be very comfortable with ICD-10, while others may be struggling, Gordon says. Implement an ICD-10 help desk staffed by power users at ease around the topic. For best results, members should come from diverse areas around the hospital, including finance, billing and IT.
Gordon suggests asking each member of this special team to go through a typical day and discuss findings with coworkers holding similar roles.
"Have them imagine their day in detail. They arrive, hang up their coat, get their cup of coffee, sit at their desk. Then what do they do? There will be some last-minute realizations—'oh, I forgot about that report!'" says Gordon.
She also suggests creating an organizational newsletter, either electronic or hard copy, to keep everyone abreast of ICD-10 related changes.
T Minus 4 Weeks
Both the leadership and finance teams should use this opportunity to make sure metrics and dashboards are in place and ready to roll out, says Jopp. "Define the key metrics executives need to be aware of. How often are they reported? What kind of thresholds are there, and what internal plan do they have to put in place to make sure they react when numbers hit certain marks?"
Lynne Thomas Gordon
The accounts receivable team should focus on getting as much off their plates as possible, says Endicott. "They need to get as much as they can out the door so they'll be ready to go on October 1."
Both Jopp and Endicott say this is a great time to start running mock cases to ensure the team's ICD-10 fluency, that third parties are correctly looped in, and that everything is all systems go.
Endicott recommends using this time to do focused education classes with anyone in the hospital who should have an understanding of ICD-10, but seems to be behind.
A vacation blackout period should be instituted, says Gordon. "At this point, it's all hands on deck. Everyone needs to be in the hospital." Check-ins with department leadership should be performed daily.
T Minus 2 Weeks
By mid-September, "you're probably still putting out last-minute fires, but most of your dry runs should be done by now," says Gordon.
"This is the final push up to implementation," says Jopp. Timelines and process should be laid out by now, backups tested, and additional backups of data and systems created.
The finance team should have gained familiarity with what dashboard measures mean by now, says Jopp, and the escalation process for different emergency scenarios the dashboards were designed to alert teams to finalized.
"This is about when coders should be feeling really confident," says Gordon. "They should know dual coding inside and out and have had intense training by now… I'm hoping they will see the light at the end of the tunnel."
"Make sure your PR department is ready," says Gordon. The local media may contact hospitals looking for sensationalistic Y2K-style stories, and you should make sure they don't get them from your organization. It is prudent to ensure frontline workers know to refer media queries to the communications department.
T Minus 10 Days Now is the time for the helpdesk team to get ready for Day One. Endicott suggests creating a phone extension where they can be reached from the end of September through the middle of October.
"There needs to be people on that team who have deep knowledge of ICD-10 and can either personally assist callers or figure out who to send questions to," says Endicott. These people will spend significant time on ICD-10-related issues over the next few weeks, so make sure their managers are aware of this.
Log issues as they are brought to the help desk. Look for trends, find solutions to common problems, and make sure issues are closed out in a timely fashion.
"I like to think everyone will have done or will do risk mitigation plans on the financial side by this point," says Jopp, who suggests having plans in place to protect revenue should there be any business systems interruptions due to ICD-10.
Take this opportunity to determine points of contact at insurance companies and electronic health record vendors. "Assume something will go wrong, somewhere," says Gordon.
T Minus 5 Days
"Organizations should have their cutover system and plan ready in addition to a disaster recovery plan," says Jopp. There should be a contingency plan in place in case the organization needs to go to paper temporarily, and processes in place for worst-case scenarios.
Teams should ensure they have a baseline for all critical success factors, says Gordon, and go-to people should be identified.
"Go over your go-live plan again," suggests Endicott. "Make sure the plans are all set."
Send out a homestretch email highlighting ICD-10-related accomplishments over the past weeks and calling out major players who have dedicated a lot of time or energy to these projects.
Clinicians and coders should also be mindful of the fact that many patients currently in the hospital will be discharged after ICD-10 goes live, and should code and document with that in mind, Endicott says.
T Minus Zero
On the night before implementation, Jopp suggests running test cases before turning on ICD-10. "Take a last look at the results and see what's happening in the controlled environment," he says. He suggests that finance take final snapshots of what life was like under ICD-9-CM before switching over to ICD-10.
"Everyone should be ready at this point," says Gordon. "Go home and get a good night's rest."
October 1
"It's hard to be the prognosticator, but I believe most larger entities will be fine," says Jopp, who doesn't think most nightmare scenarios regarding reimbursements will come to fruition.
"It will be a little chaotic for a few days," says Endicott. She suggests ensuring coders and physicians have a clear, open line of communication during this time in order to avoid a bottleneck in reimbursements due to coding errors.
Prepare last year's benchmark report—if any numbers in the days and weeks after October 1 seem wildly different, investigate to make sure it's not an ICD-10 change-related error. "It's one thing if it bounces back, but it's another if you're just not making the money you thought you would make," says Jopp.
Two Weeks Post-Implementation
"It will mean a lot to your people to be thanked for all of their hard work, the extra hours, not taking vacation and so on," says Endicott.
Gordon suggests handwritten thank you notes for a personal touch, and she and Endicott both think a hospital-wide barbeque, a spaghetti dinner, or gift certificates to local restaurants are all great ways to show appreciation.
"Cash bonuses are always nice," says Jopp. "But remember, it really isn't over. What happens two years from now, when we start learning about specificity? That's when things will really get interesting."
Many healthcare organizations now make immunization a condition for employment. Here's how to facilitate the process of getting a flu shot.
Late summer might not seem like a good time to start thinking about healthcare worker immunization, but with classes at schools and colleges already commencing and providing fresh opportunities for germs to spread, now is the time to get these programs underway.
One strong motivator: Federal regulations now require hospitals to count vaccination rates for anyone who works in a healthcare facility between October 1 and March 31.
Linda Burns Bolton, RN
In anticipation of the regulation—or as a result—many healthcare organizations now make immunization a condition for employment. "I tell [employees], you either get vaccinated or you get deployed to a non-patient care area," says Linda Burns Bolton, RN, president of the American Organization of Nurse Executives and vice president and chief nursing officer at Cedars Sinai Medical Center in Los Angeles.
Most of Bolton's workers were already happy to get their shots, maybe because she discovered a few techniques along the way to make immunization less of a chore.
1. Executive Authority "It's important to model the change you want to see in others," says Bolton, recommending a special immunization session at a board meeting for members of the C-suite to kick off the immunization push.
"The C-suite needs to not only be immunized, but they need to allow pictures to be taken, and then to allow those pictures to be used in marketing materials. When hospital leadership gets flu shots, others follow."
"Administrative support from the top down is an important part of this work," says Carolyn Bridges, MD, associate director of adult immunizations in the immunization services division at the Centers for Disease Control and Prevention in Atlanta. If hospital leadership is clearly behind immunizations, it sends a clear message that immunization is a priority at this facility.
"Make sure the recommendations around immunization are clear," she says. Also, make sure the medical staff have input in the process—once they sign on, getting everyone else to comply will be easier.
2. Educate, Educate, Educate "This is a great starting point for a conversation on the importance of immunization," says Bridges.
Bolton echoes her sentiments. "Make sure the staff understand the 'why' behind this. Assure them that we are immunizing ourselves and our patients, to protect both ourselves and our community."
Influenza vaccination has been getting a disproportionate amount of attention lately, but healthcare workers shouldn't neglect other important immunizations, including MMR, TDAP and Hepatitis. "Many adults—including healthcare workers—neglect to stay up-to-date on their immunizations," says Bridges, For example, she says, only 20% of adults under the age of 65 recommended to receive pneumococcal vaccine actually get it.
Bridges strongly recommends creating an occupational health clinic and encouraging all hospital workers take advantage of it at least once a year to stay up-to-date on required immunizations.
3. Make it Fun
Immunizations can engender feelings of discomfort or anxiety in some people, but there are ways to not only reduce these unpleasant feelings, but to replace them with positive feelings.
Bolton says she likes to up the ante by creating interdepartmental competitions to see which team can reach a 100% vaccination rate first. "You can't imagine how competitive some of these departments get," she says. Despite the fierce competitiveness, she tries to keep the prizes simple, usually offering only lunch.
Other awareness-raising activities include poster-making contests, holding a raffle for gift certificates or other prizes for workers who received flu shots, and giving out a small token of appreciation, like a piece of candy or fruit as workers get their shots.
"Always try to make it fun and engaging," says Bolton. "Anything that normalizes vaccines and conveys to healthcare workers the importance of getting them."
4. Make it Easy At Cedars Sinai, Bolton's team organizes "bands of roving nurses" called the "Flu Immunization Crew, who travel the hospital to provide vaccines. From barging into board meetings to lying in wait in the employee parking lot to nab employees as they arrive in the morning, the nurses make sure no one in the hospital can say they didn't have the opportunity to get a flu shot.
Increased opportunity to receive vaccinations and availability is one of the greatest predictors of likelihood to receive the vaccination, says Bridges. "If it's offered more than one day only, [vaccination] rates go up. If it's not available at all, those rates [of vaccination] are the lowest."
Have flu shots available to workers at every shift, and offer the shot multiple times over multiple weeks. Offering them free of charge will show workers that immunization is a priority in their workplace.
Most healthcare workers will probably want a shot provided free of charge by their employer, but some will inevitably opt to obtain one from another source—just make sure they provide documentation signed by the clinician who administered the shot.
Between motivating workers and making getting shots easy, it shouldn't be too hard to get the entire hospital onboard, says Bridges. "Having a culture where you treat immunization as a part of hospital life is key."
In a recent HealthLeaders Media Intelligence Report, healthcare leaders describe involvement in contractual relationships that stop short of a formal merger or acquisition, but M&A activity remains a dominant model. HealthLeaders Media Council members discuss their experiences with such arrangements.
This article first appeared in the September 2015 issue of HealthLeaders magazine.
Robert Shapiro
Executive Vice President
and Chief Financial Officer
North Shore-LIJ Health System
Great Neck, New York
The nature of the arrangements that our organization chooses is determined based on the entity that will be joining our system. For instance, if we have acquired another hospital, then it would fall under the corporate parent. Occasionally, there are hospitals that we don't bring in to the system right away, for a number of different reasons. At times, we enter in to an affiliation agreement, which is an agreement that we'll work together on certain activities and maybe grow a relationship over time.
From a strategic perspective, what's important is the location of a facility and whether it fits a business need in an area where we may not have a presence, its financial position and health, and, of course, clinical infrastructure. What kinds of services do they offer, and what is the quality like?
Each acquisition gets easier than the last. After you've done this enough times—the due diligence, the partnering, bringing two organizations together—you develop a sense of what we need to look at. There are fewer surprises down the road. Sometimes you find unexpected things, like understaffing or construction work that needs to be completed, but it gets easier as you learn which questions need to be asked ahead of time. There are fewer surprises.
David Zechman
President and CEO
McLaren Northern Michigan Hospital
Petoskey, Michigan
The biggest difference between being a small healthcare system trying to partner with other small, independent healthcare systems and merging with a big healthcare system is one thing: access to capital. There's capital involved in both directions. And therein lies the reason why you look to partner or merge with a larger system; a larger system clearly does have the capital to make things happen.
When I was the CEO of a small medical center approximately four years ago, we tried to set up a network of five independent rural hospitals so we could collaborate, share best practices, do some group purchasing, and maybe share some human resources, all without merging bottom lines. But while it sounds like a great idea, it's difficult to do. Our greatest challenge was finding enough capital to pull our alliance together. I believe that it could work, but smaller rural facilities generally don't have excess capital to invest in such ventures. Last I heard, the organizations involved are still trying to make that work.
Clearly, there are financial advantages to partnering with a large system. Group purchasing of supplies is a significant financial advantage. McLaren is a AA-rated system, and that allows us financial benefits in terms of borrowing money—not to mention that there's a lot of expertise at the corporate level that we wouldn't have access to if we were a standalone hospital.
Jerry Birk
Vice President of Business Planning and Strategic Development
Rideout Health
Yuba City, California
Rideout Health's primary joint venture has been UC Davis, a local academic medical center. We have a jointly owned cancer center that has been remarkably successful for the community in terms of access to tertiary-level care. Having cobranding with UC Davis is significant because members of our community recognize that they have access to a greater level of care than a typical independent, rural community hospital would be able to supply.
One of the unique qualities of this relationship is our Virtual Tumor Board. One of our own local oncologists is able to partner with the oncologists at UC Davis and have discussions virtually about care plans, status, and diagnoses.
I think this partnership enhances the quality and level of care received, and I think that when the patients see both Rideout Health and UC Davis on the side of the building, it's a brand enhancement. It's also a strong cultural fit. The two entities have embraced one another as partners, and it's been a very collaborative and successful joint venture.
I believe that there are more opportunities for regional collaboration than there have ever been in the past. The underlying premise is that we all have issues and problems, but often they are shared problems. We like to think that under shared problems there are also shared solutions that we can face together, as partners.
Larry Sobal
Vice President of Care Transformation
Ministry Health
Appleton, Wisconsin
On recent activity: Ministry has been very busy with mergers over the past few years. Three years ago, we merged with another health system here in Wisconsin, Affinity Health. A year later, we decided to join Ascension Health's nationwide network. I'd say we're still in a transitional period, and still figuring out the finer points of merging the three systems.
On changes in control: For some people who have been with Ministry for a long time, it's a very dramatic change since we're switching from fairly local control to accommodating influence from our national parent organization. Additionally, Ascension Health is currently transitioning from being a holding company to an operating company.
On finding the right partner: Cultural fit has always been the most important element of selecting partners for us. We're a Catholic entity that is descended from freestanding Catholic hospitals that did a tremendous job of instilling the Catholic mission and vision in their organizations. But, as the nuns leading these smaller health systems and freestanding hospitals age, at some point, they need to ask, “How do we ensure that our mission will continue for another 100 years?” Catholic healthcare leaders recognize that we're going to have to rely more on laypeople to drive Catholic healthcare into the future. That leaves us with the question, “Which potential partners do we share the best sense of purpose with?”
Coming federal regulations will change "white-collar exemptions" by increasing the maximum amount of salary workers need to earn before being considered exempt. Here's what hospitals need to know.
Ready or not, the overtime regulations proposed by the US Department of Labor are coming. Out for public comment through September 4, the new regs are on-track to be implemented during the second quarter of next year.
Now is the time for healthcare organizations to start making preparations for these new laws around payment, says Jonathan Kozak, employment litigator with the workplace law firm Jackson Lewis in White Plains, NY. "There is no reason to believe this won't take effect as planned," he says.
Jonathan Kozak
First published on July 6, the proposed regulations will change "white collar exemptions" by increasing the maximum amount of salary workers need to earn before being considered exempt to $50,440 annually.
I wrote about the proposed regulations last month after speaking with Kozak. Here's more of our conversation, edited for clarity and brevity:
HealthLeaders Media: Hospitals typically employ many service workers—cafeteria staff, gift shop managers, and so on. How does this affect them?
Jonathan Kozak: Most of these workers already earn under $455 weekly and are hourly employees, so I don't see the new regulations impacting those positions very much. The people this will more likely impact are those in management positions in those departments: For example, cafeteria and gift shop managers.
They may currently be considered exempt executives and ineligible for overtime, but going forward, if they earn less than $50,000 annually, they will be overtime pay-eligible. If they're not exceeding the new salary minimum, they won't be exempt, regardless as to their job responsibilities.
HLM: Should Healthcare HR consider this a good time to reevaluate which jobs within their organization are exempt and which are non-exempt?
Kozak: The fact that the regulations are changing should be an impetus to review which positions are considered exempt and nonexempt. There's likely plenty of positons in a grey area or on the borderline that are considered exempt where the change in the salary basis amount is going to make it crystal-clear that the position is nonexempt. But there are probably other positions that aren't quite so clear and will need to be closely evaluated.
One expected change that as of now has not come to fruition is primary duty analysis. Many had anticipated that the DOL would implement a quantitative analysis as to how much exempt work an individual has to perform for it to be considered their primary job duty.
Under the current regulations, there is no specific requirement as to how much time an exempt employee has to spend performing exempt work, but there was quite a bit of talk in anticipation of the regulations that there would be a quantitative review of many roles. One suggested methodology is the 50% test—if 50% of an employee's duties are not exempt, they should not be considered exempt.
The state of California has a 50% test, and many expected that the US DOL regulations would follow suit and include one as well. They did not do that, but they have asked for comments from stakeholders as to whether the primary duty test—or lack thereof—also should be changed.
That the DOL is soliciting comments on that additional change means that it's certainly possible that the final regulations will go further than just increasing the salary basis. That would be big change and would have broader impact on the applicability of exemptions.
HLM: Is it possible that hospitals will give workers shorter shifts to try to get around paying overtime?
Kozak: Yeah, I think it's possible, but I'm not sure that's an option in terms of stuff not getting done in hospitals. I mean, things have to get done, so I'm not sure if that's a viable option.
Here's how it is: Either more people will need to do same amount of work—maybe the same number of people will have to be engaged to do the same amount of work in less time—or the way people are paid will have to change in respect to newly non-exempt employees.
HLM: What about employees who work 12-hour shifts, such as nurses? Does this kind of schedule have any bearing on whether or not overtime pay is required?
Kozak: Under federal law, no. If their hours worked exceed 40 hours weekly and their income is below the minimum set by the DOL, they are entitled to overtime pay. I know that some schedules are set up in patterns that would be unfamiliar to many—like three shifts one week, four shifts the next—but whenever the individual works more than 40 hours, they will be entitled to a premium for the hours worked over 40.
The fact that an individual worked 32 hours this week doesn't have any bearing on the fact they worked 48 hours this week—they are entitled to eight hours of overtime pay for those extra hours this week.
HLM: What penalties can hospitals expect to face if they don't stay on top of this?
Kozak: There are two ways that a complaint based on misclassification can arise.
One is if the DOL receives a complaint or conducts an audit and identifies misclassified employees. In that case, the DOL can issue a finding of back wages. They would calculate what the overtime paid should have been, plus an equal amount of the back wages as liquidated damages at 100% of the back wage amount.
The second way a claim can arise is through private litigation by an impacted employee. Impacted employees on an individual or a collective basis can pursue back wages and overtime for themselves and for similarly situated persons. Within litigation, a claimant can recover liquidated damages at 100% and back wages that are owed, and they can also recover their attorney's fees. Plus employers will have to pay the additional expense of defense costs, of course.
A review of 80 studies finds that evidence-based research into hospital cleaning practices and the comparative effectiveness of different cleaning methods is uncommon.
About one in 25 US patients acquires a infection during their hospital stay, but a review of published research identified by researchers on the topic of cleaning hospital room surfaces turned up little hard data.
The review, published Monday in the Annals of Internal Medicine, found that a multifaceted approach was best to reduce the risk of hospital acquired infections (HAIs), including hand hygiene practices, antimicrobial stewardship, environmental cleansing and disinfecting. But the review also showed that many of the previous studies about cleaning hospital surfaces has been devoid of evidence-based practices, comparative studies of different cleaning methods, and patient-centered outcomes.
Now is the right time to have a conversation about hospital-borne pathogens, says the lead author of the review, Jennifer Han, assistant professor of medicine and epidemiology and associate healthcare epidemiologist at the Hospital of the University of Pennsylvania.
Jennifer Han
That's because there has been increased interest in preventative cleaning methods such as environmental cleaning—a complex process that involves cleaning surfaces to remove organic and inorganic materials, followed by disinfecting and ongoing monitoring for effectiveness—over the last year.
Common HAIs include Clostridium difficile and antibiotic-resistant strains of Staphylococcus aureus and enterococci, but Han credits the 2014 Ebola outbreak for bringing awareness and increased concern to hospital-borne pathogens, HAIs, and cleaning methods. "The Ebola outbreak made more people aware that hospital-borne pathogens can be a serious danger," she says.
Not Just Housekeeping
Han's review focused on hard surfaces such as tray tables, bed rails, and toilets—surfaces touched frequently by both patients and healthcare workers and at risk for contamination by pathogens. The researchers focused on methods used to clean hard surfaces, approaches available to monitor how thoroughly the surfaces have been cleaned, and environmental factors that either help facilitate cleaning or can create obstacles to the environmental cleaning process
Environmental cleaning can be easily confused with housekeeping, but they are very different, says Han. "Environmental cleaning is very important and very complex—and often very much behind the scenes in a hospital…. Hospitals need to emphasize that environmental cleaning is actually part of patient care-- it's not just cleaning rooms."
The review, which was commissioned and funded by the Agency for Healthcare Research and Quality, examined 80 studies, of which 76 were primary studies, and four were systemic reviews. Forty-nine examined cleaning methods, 14 evaluated monitoring strategies, and 17 addressed challenges to implementation of different cleaning methods. Of the 80 studies, only five were randomized.
"There are important gaps in evidence for what's best to clean hospital rooms," she says. Her team found that the evidence in these studies was fairly inconsistent, and thorough analysis of the data around cleaning is rare. "There was a definite surprise how much future research will be needed in this area, both in terms of rigorous comparative effectiveness studies," Han says.
Han was also disappointed by the lack of patient-centered outcomes in the studies and disheartened by the emphasis on surface contamination in each of them. "Most of the data was around pathogens on surfaces, which is really not the best metric. The current data is not around whether the patient is exposed to the pathogens or is colonized [by pathogens]," which would be more telling. Han also criticizes the lack of comparative effectiveness studies between methods.
The Future of Clean?
"What was interesting was that there seemed to be some positive studies around newer technologies for cleaning," she adds. Automated, no-touch modalities, ultraviolet light disinfection and hydrogen peroxide vapor all show promise, she says. So do technologies for monitoring contamination, such as ATB bioluminescence and ultraviolet fluorescent surface markers.
Han believes, however, that there more studies on these newer cleaning methods are needed.
Han hopes her review will help to formulate better studies on hospital cleaning in the future, and would like to see more studies that are benchmarked around evidence-based healthcare and which have clearer metrics of success for different cleaning methods.
And she hopes to see more healthcare organizations take environmental cleaning seriously.
"Many people not involved in [environmental cleaning] directly see this as something akin to housekeeping—which it's not. It's much more important. It's an important component of reducing HAIs, not just keeping hospitals clean—like hotel rooms, which they are certainly not."
Building a solid leadership pipeline holds benefits for hospitals beyond the obvious ones, experts say.
Engaged employees, strong HCAHPS scores, and a gaggle of young, eager recruits are things hospital leaders dream about. Few might make the connection that the way to achieve these things is strong succession planning and ongoing training, but one B-school professor believes a strong leadership pipeline program is the key.
The benefits of a well-developed leadership program don't stop at having several candidates for top positions, says Kevin Groves, PhD, associate professor of organizational theory and management at Pepperdine University Graziadio School of Business and Management. He is also a management consultant to several health systems, who has also written about the benefits of talent management for hospital outcomes.
Groves's research found that hospitals that have adopted talent management and succession planning best practices are associated with high scores on the Centers for Medicare & Medicaid Value-Based Purchasing metrics, which are tied to reimbursement rates for Medicare and Medicaid programs.
Kevin Groves, PhD
"We're in this situation where hospitals are transitioning from volume-based reimbursement… to value-based reimbursement. The Affordable Care Act and other legislative efforts have created an entirely new business model for hospitals," he says.
Poor succession planning can lead to decreased quality of care, which can stifle reimbursement, Groves contends. "Our revenue streams are suddenly much more dependent on the quality of our services," he says, and that time to regroup after a leader's departure is now a thing of the past—organizations need to have a plan ready.
Here are a few things that can happen when proper succession plans are in place:
1. Improved Employee Engagement "Hospitals that want high levels of employee engagement should know that the best way to move to peak engagement is through proper succession planning," says Groves.
When employees feel valued and like their organization is dedicated to helping them develop their skills and creating a strong career path for them, they're much more likely to be engaged at work says Groves.
He cites nurse turnover as an example. Organizations with strong internal training processes have nurse turnover of about 8.74% yearly, while organizations without them can expect turnover to the tune of 13.6%. While that might not sound like a big difference, it adds up—for a large healthcare system, the financial difference between the two turnover rates can be as high as $5 million annually.
John McCabe, MD
John McCabe, MD, CEO and SR VP of Medical Affairs for Upstate University Hospitalin Syracuse, NY, has also noticed stronger employee engagement and increased morale when strong succession strategies were in place in his hospital. "[Good planning] can have a lot of impact on morale… and strong staff morale can lead to an improvement in patient care."
Frequent check-ins with managers, a consistent evaluation process, mentorships, and extra training are all opportunities for ongoing conversations with employees that will keep them engaged with their jobs, coworkers, and the organization itself.
2. Improved HCAHPS Scores and Patient Experience While strong succession planning and HCAHPS scores might sound unrelated, this is simply not so, says Groves.
"Leadership stability at the top and a robust talent review process with up-and-coming leaders… drive these outcomes," says Groves. He says that experience and training in patient-centered care and outcomes are key to reaching these goals—and that strong leadership, stability, and ongoing training creates a leadership culture with long-term goals that can make patient experience a priority.
A dip in quality during leadership turnovers is a real concern that hospitals need to take seriously, says McCabe. "Leadership changes should have no impact whatsoever on patient care," he advises. If a healthcare system is structured correctly, quality of care should never be impacted by a leadership change.
With 30% of the value-based purchasing metric attached to HCAHPS scores, patient satisfaction needs to be a major part of the plan—and something that should be a big part of a hospital's culture. A well-formed leadership training program will help create leaders who are comfortable with creating sweeping initiatives for the entire health system, Groves says. "System-wide initiatives are easier to plan and just part of the job for these candidates."
3. Millennial Appeal As of the first quarter of this year, Millennials are the largest share of the American workforce; one in three US employees is between the ages of 18 and 34. With baby boomers retiring, it's vital that organizations find strategies to attract and retain young workers.
Groves believes that succession planning programs have a special appeal for millennial workers. "Millennials have a high need for frequent feedback. [Feedback] isn't just an annual review for them, but an entire, ongoing series of coaching conversations with one's manager. They want constant answers to questions like, 'to what extent are your contributions furthering your potential?' and 'does my organization value me?'"
For a Millennial, relationships with managers and the ability to learn new skills are vital. "The younger generation wants accelerated development opportunities. They want to get ahead and advance quickly. The presence alone of having a leadership academy or other program for employee development is an important part of engaging them. It helps them feel they are valued, and that they have the ability to advance quickly in their role."
Increasingly, hospitals are taking advantage of these strategies and developing strong internal pipelines, says Groves. He points to one of his client's, a health system with seven open CEO roles at hospitals within its affiliate network—that was able to find internal candidates to take six of those roles—with very little disruption to its business.
But McCabe cautions that strong succession planning won't mean the end of healthcare worker turnover as we know it. While the process of training workers to be the next crop of leaders should strengthen the culture of a hospital, it won't eliminate the need for building that pipeline.
And that's OK, he adds. "None of us should be irreplaceable."
As one healthcare system lays down the law with strict rules around employee dress—to the point of mandating underwear—it's worth asking what dress codes are really for. And is it time to relax them?
Between the influx of new residents straight out of med school and rising summer temperatures, employees may be baring more than they normally would (or perhaps should). What's the appropriate dress code policy for your organization?
Earlier this month, Akron, OH-based Summa Health System enacted a particularly restrictive dress code that not only bans visible tattoos and body piercings—which are standard strictures in dress codes—but also lists acceptable hair colors, stipulates that men's beards be kept shorter than a half-inch, requires female employees to wear hosiery with dresses or skirts, and insists that all employees must wear underwear, and that "the color, design, and style [of these garments] not be visible through clothing."
Summa Health's spokesperson, Mike Bernstein, declined my request for an interview, but he sent a statement saying that his organization "[has] a thorough dress code policy in place that is reviewed on a regular basis and updated as needed," and that "the specific requirements of the policy are designed with the best interests and safety of our patients in mind as well as to ensure the image we portray as an organization is characteristic of our outstanding reputation in the community" He says the new dress code is representative of the feedback the organization has received from patients.
Jennifer Henley
Decoding the Dress Code
Jennifer Henley, institutional board member at the National Association for Health Care Recruitmentand vice president of client services for NAS Recruitment Innovation says that dress codes help organizations convey a desired impression. "I think staff dress codes are really to promote a consistent, professional image throughout the organization," she says, adding that she believes that most healthcare workers are comfortable with most dress codes.
"Healthcare professionals are there to help their patients feel safe and comfortable, and to provide them care. I think they'll honor any particular guidelines that are in place."
But rules regarding employee dress are a contentious topic for some healthcare workers.
"I'm never quite sure what hospitals are trying to do with dress codes," says Jean Ross, RN, co-president of National Nurses United. "And when it comes down to underwear, how do you police that? Has underwear really been an issue?"
She also questions whether strict policies on body art are realistic as a growing number of young people—as many as 40% by some estimates—have a tattoo.
"I know people have their own opinions about tattoos and piercings, but many healthcare workers, including nurses, physicians, radiology techs, social workers, and nurse's aides—have them. They're increasingly common. And I don't know why there's such uproar over them. If I were a patient and my nurse were competent and caring, and she also had a stud in her nose…I wouldn't care," Ross says.
Jean Ross, RN
Ross views dress codes and strict body art policies as an attempt by employers to establish control over their image. She remembers that a hospital where she worked 35 years ago was among the last to allow nurses to wear pants. "It was in a well-to-do suburb, and the feedback the patients gave was that one of the reasons they liked the hospital was that the nurses all looked so nice in their starched white dresses and caps," she says.
"Sometimes, [dress and body art policies are] meant to appeal to a certain demographic, but very often, people who make these policies have an idea in their minds about what's proper and what isn't."
Should Tattoos Remain Taboo?
Organizational image is one thing, but there is little science behind mandating that tattoos and piercings stay hidden or that hair be dyed a natural hue.
There is zero risk of a patient getting an infection from a healed piercing or tattoo, says Scott DeBoer, RN, who is medical consultant for Association of Professional Piercers and founder of Peds-R-Us Medical Education, as well a transport nurse with MedExpress Urgent Care in Chicago.
"The bigger [safety] issue is actually on [healthcare workers'] side—if a tattoo or piercing is not healed, there's a better chance of the clinician coming into contact with bacteria from the patient and the tattoo or piercing becoming infected. But not from a nurse or physician to the patient, no."
Tattoos generally take about 45 days to heal; most piercings take about six to eight weeks.
Despite the lack of health risks to patients, DeBoer says tattoos, piercings, and other non-traditional looks just don't fit most people's ideas of how a clinician should look. "If you talk to patients, they really prefer someone more traditional in appearance…. If you look at patient satisfaction surveys around physician appearance, it's clear that patients really aren't comfortable with body art."
Scott DeBoer, RN
What's the Right Policy?
When it comes to wearing underwear, neither DeBoer nor Ross can think of any risks for either the patient or medical staff associated with going commando.
But both point out that some more commonly accepted accessories can transmit bacteria to patients.
"Several of our hospitals have policies on fake nails," says Ross, since bacteria can hide under fake nails and it's possible to accidentally scratch a patient. "Something like that makes sense to me." She also says that it's common sense to not wear dangling earrings or hoops when working in pediatrics.
So why the discomfort around tattoos, but diminished awareness around long nails and neckties?
"I think it's because it's just not the tradition," says DeBoer, echoing Ross's memories of nurses dressed in traditional attire. "If you look back at nursing, for hundreds of years it was nurses in all white dresses with the white cap. And maybe there's part of us that still wants to see that."
But here's something recruiters, HR leaders, and hiring managers should consider: The clinician shortage shows no signs of stopping. As tattoos, piercings, and funky hair color become increasingly popular, might it not make sense to consider adjusting dress codes to appeal to younger workers?
DeBoer thinks so. "With younger nursing staff, physician staff, body art, and untraditional fashion are just so commonplace. If there's a [clinician] shortage, there's a need to attract people. I'd say it's a good time to reconsider being choosy."
In our January 2015 Industry Survey, 71% of respondents describe their leadership team as strong or very strong, while just 50% can say that about their midlevel managers. HealthLeaders Media Council members discuss the imbalance.
This article first appeared in the July/August 2015 issue of HealthLeaders magazine.
Tom Dandridge
President and CEO
The Regional Medical Center of Orangeburg and Calhoun Counties
Orangeburg, SC
This imbalance is rooted more in the change in expectations we have of midlevel managers than anything else. When I first started in this business 40 years ago, managers just counted noses and made sure we had enough people to work. But now we expect a lot more from them.
The challenge has been to further develop managers as the environment has changed, and I think that's really the reason some of us feel that our midlevel managers are not as strong as we would like to see them be. But it's really important to figure out for ourselves that it's possible we're not developing them as well as we should be.
It's human nature that we senior leaders can be blinded to our own perspective, but we've got to spend more time talking to our managers. To empower them, we need to ask them questions. Do they understand management concepts? Do they understand what effect they have on their units? Do they understand how they must behave differently than they did before to accommodate and establish change?
In the C-suite, not only do we have to develop our managers, but we must recognize that the midlevel is where the rubber hits the road. I could talk all I want to about cost efficiency, but unless a midlevel manager implements cost-efficient measures, they're not going to happen. It's the midlevel managers that bring plans to life.
Steve Long
President and CEO
Hancock Regional Hospital
Greenfield, IN
In our larger metro area, there's lots of opportunity, and in a small to midsize hospital like ours, the organization structure is pretty flat, without many layers of leadership. So, when really good potential midlevel managers are looking at available positions, they kind of realize that when they come to a place like this, the opportunities for advancement are fairly few and far between.
Attracting talent is different for different organizations. A very large organization in a metro area where there is lots of opportunity for advancement will likely have more candidates to choose from.
Now, all that said, midlevel managers are not usually, especially in smaller organizations, brought in from the outside. They are usually selected from frontline technicians who are already working there. We, as an industry, take the very best technician we've got and say, "Wow, they would be a great manager," and plop them into the management role—and rarely does anyone invest in leadership education or training. We just drop them in there and tell them, "Good luck with that." And when they fail, we're surprised, because they were so good at being a technician. We are blessed at Hancock Regional Hospital to have exceptional midlevel managers and have understood that continuing leadership development is vital to the future of our organization.
Bruce Elegant
President and CEO
Rush Oak Park (IL) Hospital
On the move from middle management to C-suite: Frequently, we will get a strong midlevel manager, and they will become so good at their role that when other opportunities in the organization present themselves, we're hesitant to promote them because we'll lose them for the role that they're already doing exceptionally.
We do have a preference—and make it a priority—to promote from within, but it's not always possible. Unless you have an obvious "next-in-line" employee who is particularly strong and ready to go, you reluctantly sometimes go outside the organization to fill the position.
On training midlevel managers for the C-suite: Over the past year, the Rush healthcare system started a leadership academy. We're identifying midlevel leaders with high potential and carving time out for them to enroll in some continuing education with regard to how to become a more effective leader.
The training really puts potential leaders in a position where they're networking and learning from others. We have some team members in the human resources area who are teaching them skills such as time management, how to evaluate employees in a more effective manner, and, if they require remediation in anything like financial analysis, then we focus on those skills. Some of the training is academic, but a lot of it is networking and getting feedback from your peers and current leaders.
Michael Wiechart
President and CEO
Capella Healthcare
Franklin, TN
I was quite surprised to hear these statistics, because I think that if we were to poll our organization, we would probably find that we have equal confidence in our midlevel managers as we do in our leadership team.
Our strategy for securing and maintaining top talent has been something that is very important to our company's culture over the years, and something that we have invested heavily in. In order to attract strong managers at every level, it's vital to provide a workplace where people are proud to serve. This means having a commitment to providing the highest quality of care first and foremost, and frankly, fair compensation second.
To keep strong managers at all levels, including midlevel management, it's important to have a culture in which people are held accountable. If poor performers are allowed to remain in the workforce, it is demotivating to everyone, and it's completely defeating to those managers who have the ability to be outstanding.
When we recruit or attempt to retain talent, candidates understand that they have to share our top priority. If the conversation starts there, whether you're talking about the leadership team or the midlevel managerial level, it only strengthens or edifies our relationship with our leaders and ensures that the right engagement is in place.