Measuring Productivity: Finding the Right Quality Quotient
Productivity and Measurement | Establishing Productivity Expectations |
Long Term Care Facility Driven Productivity Model |
Analyzing Productivity Indicators | Managing from Measurement | Summary | References
by Patricia G. Larkins
Patricia G. Larkins is Vice President of Professional Services at NovaCare, Inc. She is a member of the ASHA Task Force on Clinical Standards.
The shortage of rehabilitation professionals, yet increasing the demand for rehabilitative services, and escalating costs are forcing consumers to question productivity. Consequently, speech-language pathologists and audiologists are being asked to demonstrate their productivity to meet the demand for their services at the lowest possible cost. This issue of the Quality Improvement Digest addresses productivity and the importance of measurement, provides a conceptual framework from which to establish productivity standards, and describes how information obtained from productivity measurement can be used to manage speech-language pathology and audiology services more effectively.
Productivity and Measurement
Productivity is traditionally defined as the ratio of output to input. Bain (1982) describes it as a measure of resource utilization to achieve specific results. In healthcare, Batten (1984) states output is measured in units of service or units of measure (e.g., client days, procedures, discharges).
Productivity = output divided by input = results achieved divided by resources consumed
Input is quantified in terms of employee time. Typically, the primary focus of productivity measurement in rehabilitation is the number of units (amount of time) clinicians generated based on clients seen. For purposes of this discussion, productivity is defined as client care management. That is, the management of the number of clients on caseload and the amount of time a clinician spends with each client. Time is referred to in units (i.e., one unit = 15 minutes). Given this frame of reference then, the primary goal of productivity management is to ensure that all clients in a given facility in need of speech-language pathology or audiology services receive them within a reasonable amount of time and, as a result, function more independently.
That which gets measured gets managed. In the absence of measuring productivity, many clients in need of services may not receive them, may be discharged from caseload prematurely, or may depend on the support of others unnecessarily. Conversely, clients who do not need services could be receiving them, staying on caseload too long, or making no change in functional status. It is not easy to measure productivity because the results achieved may be dependent on many different inputs (e.g., inadequate space, staff skill level, management's effectiveness). The manner in which these factors interrelate has an important effect on productivity results.
The influence of the above factors must be considered as results are analyzed. These factors, however, must not be used to inhibit measurement. Remember, that which gets measured gets managed." Emphasis on only quantity of output can negatively affect the quality of the outputs. It is important then to include quality measurements into the overall productivity measurement system.
The benefits of productivity measurement are numerous. Bair and Gwin (1985) report that productivity data facilitate the ability to increase efficiency by integrating financial and planning information to ensure more fiscally viable products and services without sacrificing the quality of care. In the budgeting process, productivity data provide additional information about direct and indirect expenses. These expenses are correlated to program objectives and projections regarding caseload size. Revenue or income predictions are based on projected total expenses. Hence, analyzing productivity data allows the manager to assess how much time is being spent in direct service (activities that directly benefit the client or caregiver) and indirect service (activities that result in no direct benefit to the client or caregiver).
Productivity measurement also provides useful information on average length of treatment, staffing patterns, reimbursement patterns, diagnostic groups, and treatment outcomes. Analyzing these data provide information that can assist in personnel projections, improving staff effectiveness, creating new programs, and containing or reducing costs.
Productivity measurement benefits the clients and customers (e.g., payors, peers, and other professionals) we serve. Our ability to be competitive in healthcare and education in the future is contingent upon our ability to measure productivity.
Establishing Productivity Expectations
Productivity expectations are influenced by the facility in which clinicians work. That is, clinicians can only be as productive as their work environment. The following section describes a facility-driven model that was developed at NovaCare, Inc. for use in long term care facilities. This model includes key facility variables used to determine the number of clients on caseload, the amount of time expected to be spent with clients, and staff needed to manage the caseload. Based on these projections, productivity expectations for clinicians are determined. It is hypothesized that this conceptual framework is applicable across work environments.
Long Term Care Facility Driven Productivity Model
Key Facility Variables
The first step in developing this model involved identifying key facility variables that had the most significant effect on productivity. A task force comprising representatives within the NovaCare organization, including managers and direct service providers, identified the following key variables: number of beds, case-mix, length of stay, Medicare Part A days, payor source, and physical space. Each variable was defined to ensure that clinicians would be consistent in profiling their facilities. For definition of the key variables in this model, see Table 1.
Facility Profile
The second step involved in developing this model included determining the facility profile. Clinicians met with their managers and collaboratively decided upon an approach for obtaining the information needed for each variable. This approach included identification of: NovaCare staff responsible for completing the profile, facility staff to be involved in the data collection process, and records needed for review. Table 2 provides examples of two facility profiles.
Calculating Productivity Expectations
Productivity expectations could best be determined by the team within the facility. Hence, step three involved a meeting of the team and manager to review the facility profile. After discussing each variable, each discipline then estimated the number of residents expected to be seen for rehabilitation (#PTs); the amount of time that would be needed to work with the residents
Table 1. Key Facility Variables
| Key Facility Variable |
Definition |
Rationale |
| # Beds |
exact count of beds within facility |
indicates facility size |
| Case-Mix |
% of all admissions with history, medical diagnosis, appropriate for rehabilitation services |
indicates existing potential for rehabilitation |
Length of Stay (LOS)
|
average # days from admission to discharge |
indicates turnover of residents |
| Medicare Part A days |
total # resident (client) days reimbursed by Medicare Part A for facility |
indicates number of residents in need of frequent/intense intervention (per Medicare Part A requirements) |
| Payor Source |
# residents with reimbursement/total residents (%) |
indicates reimbursement guidelines that must be followed |
| Space |
square footage for rehabilitation services |
indicates available space to provide rehabilitation |
Table 2. Facility Profiles
| Facility Profile A |
Facility Profile B |
| # of Beds |
120 |
# of Beds |
100 |
| Case Mix |
50% |
Case Mix |
|
| LOS |
90 - 120 days |
LOS |
>1 yr. |
| Medicare Part A |
6,000 |
Medicare Part A |
1,000 |
| Payor |
90% |
Payor |
30% |
| Space |
900 sq. ft. |
Space |
180 sq. ft. |
(UPP); and the number of full-time-equivalent staff (FTE) needed to manage the projected caseload. After the projected caseload size and staff needs were determined, the productivity expectation for each clinician was calculated using the formula:
#PTS x UPP divided by FTE= UPC
Based upon the profiles described previously, productivity expectations were determined, as indicated in Table 3. These data confirm the hypothesis that productivity expectations will vary depending upon the facility.
Table 3. Productivity Expectations
Facility Profile A
Productivity Expectations |
Facility Profile B
Productivity Expectations |
| |
#PTS |
UPP |
FTE |
UPC |
|
#PTS |
UPP |
FTE |
UPC |
| SP |
11 |
20 |
2 |
110 |
SP |
1.8 |
15 |
.25 |
108 |
Analyzing Productivity Indicators
Given the productivity expectations determined by the facility, the question presented by the managers to the facility team is: "Can we have a more viable practice within this facility?" Step four includes analyzing productivity indicators. A more viable caseload can occur if either more residents are on caseload or more time is spent with residents on caseload. Therefore, a number of indicators are analyzed as specified in Table 4.
Table 4. Productivity Indicators
Productivity Indicators for Number of Residents on Caseload
- Case Mix
- Screenings
- Evaluation
- Referrals
- Occupancy vs. census
- Admissions
- Discharges
- Inservices
- Clinician time in facility
Productivity Indicators for Amount of Time with Residents (UPP)
- Frequency, Intensity
- Direct vs. documentation and preparatory time
- Payor source
- Case Mix
- Discharge
- Clinician time in facility
Based on the analysis of these indicators, a facility action plan is developed that includes objectives, actions to be taken, timelines and follow-up. An example is provided in Table 5.
Table 5. Action Plan
Facility B Action Plan
Objectives:
- To increase facility staff understanding of rehabilitative services
- To increase case mix
Actions:
- Present dysphagia inservice to nursing staff (6/4)
- Analyze community sources for referral to nursing homes (6/10)
- Meet with Administrator to develop marketing plan to attract more residents
with rehabilitation potential (6/30)
Follow-Up:
- Measure # dysphagia referrals from nursing
- Meet with community sources for referral about rehabilitation programs in
Facility B
In order to ensure that productivity expectations are met and remain realistic, it is important to measure continuously. A patient tracking log (Figure 1) was developed by the NovaCare task force as a tool both clinicians and managers could use to ensure caseloads were being managed both effectively and efficiently.
This form allows a professional, at a glance, to determine: (1) what-type clients get on caseload, (2) how much time is spent with them, (3) how long they stay on caseload, (4) how much they improve, and (5) where they go upon discharge. Additionally, this form allows tracking of timelines of screening, evaluations, treatment, and discharge. Analysis of referral patterns is also possible. This tool provides for ongoing assessment of caseload management.
Managing from Measurement
Measurement of practice is too often viewed negatively. Many perceive it as a way of identifying problems or catching people doing things wrong rather than an indicator for problem resolution. Data obtained from productivity measurement provide useful information about clinical practice. This information can be used to: meet client needs, promote speech-language pathology and audiology services, advocate for clients, improve reimbursement and regulatory requirements, and improve continuously service delivery. Examples of reports that are being used at NovaCare include:
Referral patterns:
quantifies percentage of screened residents referred to various healthcare team members; provides informa-tion that can address the question: Are all residents being referred to appropriate team members?
Case mix:
quantifies percentage of residents in facility by medical diagnosis, and by rehabilitation diagnosis; provides information that can address the question: What percentage of residents are potential candidates for rehabilitation? Are all rehabilitation residents on caseload?
Length of stay (LOS):
quantifies length of time resident has been on caseload; provides information that can address the question: Are residents being seen for the appropriate amount of time?
Resident outcomes:
quantifies residents' functional gains from admission to discharge; provides information that can address the question: Are residents functioning more independently upon discharge?
Payor mix:
quantifies percentage of residents on caseload by payment source; provides information that can address the questions: Are all Medicare Part A residents being seen? Are all Medicare Part B residents being seen? What is the distribution of payors?
Service delivery efficiency:
quantifies timeliness of screenings, evaluations, and discharges; provides information that can address the questions: Are screenings being completed to meet federal requirements? Are evaluations conducted within reasonable time from date of referral? Are residents being kept on caseload too long or are they being discharged too soon?
Summary
In an era of cost containment, with a focus on fraud and abuse, it is imperative that we work toward achieving desired outcomes. This can be demonstrated by managing caseloads effectively and efficiently. Measurement is a key aspect of management. That which gets measured gets managed. Take a look at your work environment. Identify and define the key variables that influence productivity. Create a facility profile, review it and determine the number of clients appropriate for your caseload and the amount of time you will need to spend with them. Ask yourself, "Is this a viable practice or can it be better?" Use the productivity indicators and measure on an ongoing basis. Take the data and make it meaningful information that can be used to enhance your practice, promote your profession and enhance the quality of the lives of the persons you serve.
References
Bain, D. (1982). The productivity prescription - New York: McGraw-Hill Book Company.
Bair, J. and Gwin C. (1985). A productivity systems guide for occupational therapy. Rockville, MD: The American Occupational Therapy Association, Inc.
Batten, G.R. (1984). Enhancing productivity in health care facilities. Owings Mills, MD: National Health Publishing.
Hanks, K. (1986). Up your productivity. Los Altos, CA: William Kaufmann, Inc.
Gray, S.P. and Steffy, W. (1983). Hospital cost containment through productivity management. New York: Van Nostrand Reinhold.
Simon, S.E. (1983, November). Work measurement methods: An approach to productivity management in the human services. Journal of Rehabilitation Administration, 151-163.
Templin, J.L. (1983, April). Productivity in the supervisor. Health Care Supervisor, 1-11.