HCM 413 Long Term Care Administration

1
HCM 413 Long Term Care Administration

• Part Two Human Resources

2
Goals

• The goal of TQM is that human resources in every
  unit arrive at a level of daily performance
  reflecting a passion for quality.
• Easier said than done.
• The decision on how to staff a nursing facility
  depends on many variables. Medical complexity
  plays a part, a significant part.

3
What is the organizational pattern for a 100-Bed
facility?

• Figure 2-1 on page 120 shows the organizational
  pattern and staffing levels for a 100-bed
  facility as recommended in the Federal government
  regulations.
• Note that the 17 departmental areas are
  frequently given different titles and combined in
  different ways.

4
Further

• Workable variations on this model exist. In this
  model, the administrator has responsibility,
  directly or indirectly, for all the functions of
  the facility. A variant to this model might
  incorporate the distribution of several functions
  to mid-level managers.

5
The Administrators Office

• The effective administrator does whatever it
  takes to have effective control of resident care
  in the facility.
• Additionally, the administrator is responsible
  for resident rights.
• Specific responsibilities are listed on Page 122

6
The Assistant Administrator / Administrative
Assistant

• An assistant administrator has line authority to
  represent the administrator, and can make
  decisions on the administrators behalf. This
  does not apply to the Admin. Assistant.
• Note that in a 100 bed nursing facility, there is
  usually not an assistant administrator 300 or
  more beds would have an Asst. Admin.

7
Secretary and Advisory Functions

• As a rule, the Administrator has several advisory
  persons or groups, to include the medical
  director and resident council. Further, a
  pharmacist or dentist might fall into this
  category.

8
Medical and Allied Health Functions

• The typical 100- bed facility does not require
  the services of a full-time medical director. The
  medical director is normally paid a contractual
  monthly fee to provide medical supervision.

9

• The Open Medical Staff
• The predominant pattern for nursing facilities of
  approximately 100 to 200 beds is to allow any
  physician licensed to practice in the state to
  admit patients to the facility and to provide
  their medical care while they reside there. The
  medical director, than, will ensure that the
  needs of the patient are being met, and
  substitute for the personal physician as needed.

10

• The Closed Medical Staff
• A second model of medical direction is the closed
  medical staff. This means that only physicians
  approved by the organized medical staff of the
  facility may admit or treat its patients.
• An organized medical staff is the closed group of
  physicians who provide all the primary care to
  the patients.
• Closed medical staffs are more feasible for
  larger facilities.

11

• Further, a closed medical staff has advantages.
• One of them can be on duty or on call at all
  times.
• Because the physicians have some dependency on
  the facility, the administrator will have
  available the required services.

12
Other medical and allied care

• Dental care a major but often neglected service.
• Foot and eye care there is a need for a
  podiatrist to treat foot conditions, to include
  sequela from diabetes.
• Pharmaceutical Services for reviewing the drug
  regimens and addressing problems with drugs.

13

• Physical, Occupational, and Speech Therapy.
• Lab and other diagnostic services, which may be
  on premises or contracted for at a local hospital
  or private hospital.

14
Nursing Services

• A comprehensive listing of nursing service
  responsibilities is listed on Pages 132 and 133.
• With all of these duties, it is not surprising
  that some things dont get done as acceptably as
  one would desire. Performing acceptable
  assessments and care plans remain a challenge in
  15 of facilities.

15

• Figure 2.3 on Page 135 breaks out the division of
  nursing hours among RN hours, LPN/LVN hours, and
  nursing aide hours. The main change over 1993 to
  2005 was to slightly decrease the more expensive
  RN time and slightly increase reliance on nurse
  assistants.

16
Increasing dependency on nursing assistants

• The nursing home population is heavily dependent
  on the nursing staff, especially the nursing
  assistants. The five essential activities of
  daily living are
• Eating
• Dressing
• Toileting
• Bathing
• Transferring

17

• In 2003, for all persons in the US age 65-74, 26
  had limitation of activities caused by chronic
  conditions for all persons in the US aged 75 and
  over the limitation rises to 44.
• Limitations among the nursing home population are
  dramatically more debilitating.

18
Staffing

• Three nursing shifts, 24 hours a day, 365 days a
  year offer a staffing challenge.
• The proportional ratios between registered
  nurses, licensed practical nurses, aides, and
  even geriatric nurse practitioners will vary with
  the staffing philosophy of the administrators
  and the patient profile.

19
The Business Office

• Part 3 of the text is devoted to finance, which
  includes the work of the business office.
• Briefly, though, the business office keeps
  financial records, manages accounts receivable
  and payable, maintains vendor files, assists in
  monitoring the budget, keeps records, deals with
  payers, safeguards residents funds, and other
  duties.

20
Medical / Patient Care Records

• By Federal requirements, a full-time employee
  must be assigned to keep the medical record
  service up to date. This person may also be
  called a ward clerk. Of primary importance is the
  medical record, and the need to keep it up to
  date and complete.
• Documentation truly does count.

21
Admissions

• In states where first-come first-served rules do
  not exist, the person or persons in charge of
  admissions influence the case mix of the
  facility.
• Usually a person with a social work background is
  employed as the admissions coordinator, and this
  person may perform duo functions.

22

• The admissions persons must find, screen,
  process, facilitate, and manage case mix, while
  balancing financial, light versus heavy care, the
  goodwill of the hospital discharge planners, and
  managed care of other source elements.
• They are important promoters of the facility,
  marketing to physicians, discharge planners, 3rd
  party payers, etc.

23

• Make the admissions process easy.
• Consider having a web site.
• When meeting a prospective referral source, greet
  the customer, listen to the customer, identify
  their needs, and ask for their business.
• It is estimated that every lost admission can be
  a 90,000 loss to the facility.

24
The Dietary Department

• Food is an essential ingredient in the quality of
  resident / patient life.
• Satisfaction with the facility is as often
  influenced by the food as by the quality of
  nursing care.
• It appears that about 10 of the time nutritional
  needs are not being met.
• Also of concern, and a major area in need of
  improvement, is sanitary conditions.

25

• Note that the dietary manager in the typical
  nursing facility (70 Medicaid, 15 Medicare, 10
  private pay, 5 other) is permitted to spend 4
  to 5 per day for raw food costs.
• The typical life care community (nearly 100
  private pay) spends 12 or more per day for raw
  food costs.

26
Further

• The dietary departments influence extends 24
  hours a day (bedtime snacks, midnight snacks for
  insomniac patients, etc.).

27

• The administrator can monitor food services in a
  number of ways. Randomly timed walks through the
  kitchen, eating with residents in the dining
  hall, assisting with feeding in resident rooms on
  a daily basis might be ways to stay in touch.

28
Social Services

• The social worker is concerned not only with the
  residents initial adjustment to the facility,
  but also his or her continuing accommodation to
  the environment.
• It is also the social worker who is often most
  directly in contact with the residents family or
  significant others.

29
More on social services

• The overall goal is to meet, as able, social,
  psychological, physical, environmental, family,
  financial and related needs. While the social
  worker is not responsible for all of these needs
  being met, he or she can stimulate the various
  other staff members to participate in this
  process.

30
Activities / recreation

• While nursing services primarily address the
  medical needs of the patients, and in doing so
  partially meet their social and interpersonal
  needs, it is the task of the activities
  coordinator to ensure that the physical, social,
  and mental well-being of each resident is
  included in each resident assessment.

31
Housekeeping

• Dirty floors and walls, empty toilet paper
  holders, yellowing toilets and offensive odors
  associated with them, communicate a message to
  the patients, staff, and visitors that reveals
  what the facility thinks about itself.

32

• Note that a surprising amount of regulation
  surrounds the housekeeping area, from the storage
  of chemicals to bacteria counts.
• By 1999, 85 of facilities were meeting
  housekeeping requirements.

33
Laundry

• Clean linens, clean resident clothes, the
  availability of linens and clothes when needed,
  and safe, sanitary handling techniques for both
  soiled and clean linen are areas of
  responsibility of the head of laundry.
• Note that laundry can be done in house or
  contracted with an outside vendor.

34
Maintenance Department

• There can be some confusion between what
  maintenance and housekeeping is responsible for,
  but the repair and upkeep of physical systems is
  clearly the responsibility of maintenance.
• Preventative maintenance is especially important.

35
Identifying the Human Resources Functions

• The long term care administrator, than, will be
  involved in various human resource functions, to
  include
• Record keeping
• Recruitment
• Selection
• Training and retaining employees
• Compensation
• Performance appraisal
• Labor relations
• Health and safety

36
When planning employment needs

• Complete Job Descriptions (a statement of the job
  to be done, including a list of duties).
• Job Analysis (the physical aspects of the job).
• Job Specifications (a statement of the skills,
  education, and experience required.

37

• Job titles, or job classifications.
• Tasks, or the coordinated and aggregated series
  of work elements use to produce an output.
• Position, or the responsibilities and duties
  performed by one individual.
• Job, or a group of positions that are similar in
  their duties.
• Job Family, or a group of two or more jobs that
  have similar duties.

38
How do you forecast employment needs?

• The planning process begins with a projection of
  the number of residents and their expected levels
  of medical complexity that the facility expects
  to serve over a period of time, usually during
  the following 1 to 5 years. This forecast can
  then be translated into specific personnel
  requirements for the future.

39

• Once the forecast is made, recruitment can begin.
  Sources can include present employees, job
  postings, outside sources, referrals,
  advertisements, public and private employment
  agencies, search firms, professional and industry
  organizations, educational institutions, and
  electronic recruiting and screening.

40

• If recruitment is the process of locating
  prospective staff, than personnel selection is
  the process of deciding which of the applicants
  best fits the requirements of the job for which
  they are being considered.
• When applicants are chosen wisely, they tend to
  adjust more quickly and have greater job
  satisfaction.

41

• There are a variety of methods for learning about
  applicants, to include written application forms,
  interviews, and background checks.
• Information needs to be reliable and valid.
  Reliability refers to the consistency with which
  the same results are obtained over time. Validity
  refers to something actually measuring what it
  was intended to measure.

42
Two kinds of validity

• Content Validity the degree to which a test,
  interview, or other selection tool measures the
  skills, knowledge, or performance actually needed
  on the job.
• Construct Validity the extent to which a
  selection tool measures a trait or behavior that
  is perceived as important to functioning in a
  job.
• These two seem to measure different things.
  Content Validity is concerned with skills, etc.,
  while Construct Validity is concerned with traits
  or aptitudes, etc. More detail can be found on
  Page 166 of your text.

43

• Be very careful about the kinds of pre-employment
  questions you ask- some may be illegal!
• In particular, disability-related questions,
  national origin, age, religion, etc. questions
  are wrought with risk.
• See page 169 -171 for lawful and unlawful
  questions.

44
Re interviewing methods

• They vary, but generally are classified by three
  types of structure
• Nondirective
• The interviewer refrains from influencing the
  applicants remarks.
• In-depth
• Provides more structure in the form of specific
  question areas to be covered.
• Patterned
• The least amount of freedom to both the
  interviewer and the applicant. All questions are
  sequential and highly detailed.

45
What does research tell us about the use of
interviews?

• Structured interviews are more reliable than
  unstructured interviews.
• When there is more information about a job,
  inter-rater reliability is increased
• Factual written data is better than physical
  appearance.
• Allowing the applicant time to talk provides a
  larger behavior sample.
• An interviewers race affects the behavior of the
  person being interviewed, etc.

46
Re background investigations

• Background checks are increasingly important, and
  should reveal information re credit standing,
  required licenses, criminal background checks,
  gaps in employment, etc.

47

• After the screening process is completed, a
  decision of who to hire can be made (using either
  a clinical approach using all of the information
  at hand to decide or a statistical approach,
  using the most valid predictors, which are than
  weighted).
• Lastly, the job must be offered, and information
  such as salary, job title and level, starting
  date, etc. should be shared.

48
Following hiring

• Orientation, to include introduction to the human
  resources policy handbook and training (as
  needed).
• The purpose of orientation is to provide an
  initial introduction to the new employee. The
  purpose of training is to communicate the
  organizations needs to the staff and assist them
  in meeting those needs.
• This is a continuous process

49
Retaining Employees

• Employees require of the facility five different
  things
• 1. Social approval
• 2. Self-esteem
• 3. Security (economic)
• 4. Accomplishment
• 5. A sense of purpose

50
Strategies to meet employee, and facility, needs.

• Attempt to meet the social, self-esteem,
  security, and other needs, and your staff will be
  motivated and satisfied.
• What motivates staff?
• Theory X and Y beliefs.
• Maslows Hierarchy-of-need concept.
• Personality Types A and B.

51

• Check out the Exercise on Page 195.
• Supervisors ideas about what motivates the staff
  and employees ideas about what is motivating
  often differ significantly. The exercise provides
  a list of concepts the reader can ask of a set of
  supervisors and employees in their facility
  regarding what they consider the most important
  aspects of their jobs.
• See next slide

52

• Things such as
• Being treated fairly
• Consistency from management
• Job security
• Interesting work
• Good wages
• Full appreciation for work done
• Good working conditions
• Promotion and growth opportunities, etc.

53
Evaluating Employees

• Job performance evaluation is a task assigned
  only to line managers.
• A basic purpose of the job performance evaluation
  is to focus the energies of the employee on the
  performance level expected of him or her.

54

• The Performance Evaluation has three basic
  objectives
• 1. to give employees feedback about their work
  performance.
• 2. to provide a basis (plan) for directing future
  employee efforts toward org. goals.
• 3. to provide a basis on which managers will
  decide on promotions.

55
Methods of rating employees

• Rating Scales, which list a number of
  characteristics, traits, etc. of the employees
  position on a line or scale.
• Errors made by Mgrs. using the scale
• Leniency error- or high ratings.
• Central tendency- moderate scores.
• Halo effect- one positive trait influences
  others.

56
Compensation

• Generally considered the reward given to
  employees in exchange for their work effort.
• Equity Theory states that employees seek an
  exchange in which their wages and benefits are
  equal to their work effort, especially when
  compared to wages and benefits paid to similarly
  situated coworkers.

57
Lastly, disciplining employees

• For most offenses, progressive discipline-
  beginning with verbal warnings, followed by
  written warnings for any subsequent violations-
  makes the most sense.

58
Actual Writings on Hospital Charts

• The patient was to have a bowel resection.
  However, he took a job as a stock broker instead.
• The pelvic exam will be done later on the floor.
• Patient was seen in consultation by Dr. Blank,
  who felt we should sit on the abdomen and I agree.

59
And finally...

• Large brown stool ambulating in the hall.
• Patient has two teenage children, but no other
  abnormalities.

60
Twisted Sayings

• Does the name Pavlov ring a bell?
• I used to think I was indecisive, but now Im not
  sure
• My reality check just bounced
• IRS Be audit you can be