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Q: Organizational Structure ( Answered 3 out of 5 stars,   1 Comment )
Question  
Subject: Organizational Structure
Category: Business and Money
Asked by: rags500-ga
List Price: $50.00
Posted: 14 Dec 2002 17:42 PST
Expires: 13 Jan 2003 17:42 PST
Question ID: 124770
What are the fundamentals to be considered when defining an
organization structure for a Continuing Care Retirement Center with a
SNF.

Request for Question Clarification by pelican-ga on 15 Dec 2002 00:06 PST
1. The acronym "SNF" stands for "Skilled Nursing Facility" -- right?

2. Could you kindly clarify what you mean by "organizational
structure"?  Would this include, for example: mechanistic versus
organic organizations, profit versus non-profit, function versus
matrix, organizational goal setting, organizational performance
measurement?  Others?  Please let me know.

3. What kind of organization structuring "fundamentals" do you have in
mind?  Would  one of these fundamentals be "organize for providing
physical care" versus "organize for enhancing the quality of life of
the residents"?  Others?  Please let me know.

Thanks,
pelican-ga

Clarification of Question by rags500-ga on 15 Dec 2002 13:04 PST
SNF does mean Skilled Nursing Facility.

Within the total community, there are Housekeeping, Dining Services,
Nursing, Marketing, Maintenance, Marketing, Administration type
departments.  However, in the current setup, these areas report
directly the the Executive Director.  Within the Skilled nursing
facility (SNF), the administrator must relie upon the other department
heads to correct State Survey issues within the SNF.  These
departments do not know, understand or care about the regulations
covering the SNF.  Their concern is only the needs of the Independent
living community.

I am proposing to change the organization so that the individuals
within the SNF report to me the administrator, but I need a good basis
for making the argument.

Request for Question Clarification by pelican-ga on 15 Dec 2002 20:52 PST
Your clarification was very good, but here you lost me:

"These departments do not know, understand or care about the
regulations covering the SNF.  Their concern is only the needs of the
Independent living community."

How is it possible for the SNF departments not to care about the
regulations (state regulations, right?) since those regulations define
the needs of the resident community and, in some vases, also prescribe
how to best meet those needs?

Then you wrote:

"I am proposing to change the organization so that the individuals
within the SNF report to me the administrator, but I need a good basis
for making the argument."

OK, let's see if I can help you with this.  There are basically two
goals for Continuing Care Retirement Centers, specially those with
SNF:

1. To provide cost-effective physical care to frail and impaired
individuals.
2. To provide the best possible quality of life of the residents.

Based on preliminary research, I get the impression that goal 1 has
been the dominat one in the past.  I also get the impression that,
while goal 1 will continue to be a priority, the trend going forward
is to put more emphasis on goal 2.  Do you think I am on the right
track?

If so, then a successful argument for re-organization would be to show
that, ceteris paribus, all SNF departments reporting to you will
continue achieving goal 1 *and* will make it possible to achieve goal
2 in a more cost-effective manner -- do you agree this is the correct
approach?

There is an article in the Washington Post today you may want to read:

"Whose Comfort Are They Managing?", by Leonard Laster, Washington
Post, 15 December 2002, p. B5.  It is available online:
http://www.washingtonpost.com/wp-dyn/articles/A53420-2002Dec14.html

I think the article is relevant to your questions, because it
describes some of the sensitive trade-offs between goal 1 and goal 2;
and how the trade-offs are resolved will determine (or at least
influence) the way to organize in the years ahead.  Let me know your
thoughts on this, so I can get to work on solid ground.

Thanks,
pelican-ga

Clarification of Question by rags500-ga on 16 Dec 2002 10:56 PST
Yes, it is possibile because they concern and major emphasizes is in
the Independent Living.  They have never dealt with the Skilled
Nursing Facility.  None of them know the regulates.  Previous attempts
to hold accountablity for SNF results have failed as the department
heads do not report to the "responsible" SNF person.  Management by
conscience only works if you have the authority to go beyond please.

This organizational structure has been in place for 5 years and in
each of teh 5 years the State Survery of the SNF has gone downhill.

Clarification of Question by rags500-ga on 16 Dec 2002 10:57 PST
The article and you write was on the right track.  Thanks.

Request for Question Clarification by pelican-ga on 17 Dec 2002 14:07 PST
Hello rags500-ga,

I am working on your question.  Could you tell what kind of questions
they use in the State Survey to evaluate SNF performance?  A list of
the questions would be ideal.  If this is not possible, tell me what
you can about the questions asked and the data collected during the
survey.  And this survey is done annually, right?

Thanks,
pelican-ga

Clarification of Question by rags500-ga on 30 Dec 2002 04:39 PST
The questions are not available to anyone outside of the State Survey
team.  They normally ask for an Organizational chart, then do audits
to determine if the chart reflects the true organization.  The
surveryor asks such questions as "If you have a question about
regulations, who do you as?"  "What is the name of the person you
provides day to day directions.  Most of the questions are along this
line.  When enough questions are asked of 4 to 5 lead supervisors,
then the true organizational chart is developed.

Request for Question Clarification by czh-ga on 30 Dec 2002 18:38 PST
Hello rags500-ga,

I’ve been doing some preliminary research for your question and my
explorations have led me to the conclusion that changing the
“organizational structure” of your situation may not be the best
answer to your problem.

Here are the facts I know about your situation. You work for a
Continuing Care Retirement Community (CCRC) that is headed by an
Executive Director. Such communities usually offer three levels of
care: Independent Living, Assisted Living, and Skilled Nursing
Facility. You’ve indicated that you are the Administrator of the
Skilled Nursing Facility in your CCRC and that there is also an
Independent Living arrangement that is administered by someone else.
It’s not clear if your CCRC also offers Assisted Living
accommodations. It’s also not clear whether the Executive Director
that you report to manages the Independent Living unit or if someone
else administers that and they also report to the Executive Director.

The entire CCRC shares the services of functional units in the
organization, i.e., Housekeeping, Dining Services, Marketing,
Maintenance, etc. You are frustrated because you feel that these
departments are not helping you meet your obligations to your
clients/patients. The services that you must deliver are mandated and
regulated by State agencies which conduct standardized compliance
Surveys. The Independent Living administrator does not have similar
obligations. You feel that the functional units in the CCRC are not
giving you sufficient support and you believe that changing the
organizational structure so that you would have such authority would
help you solve your problem.

The preliminary research I’ve conducted leads me to believe that there
are other ways to approach your problem of delivering high quality
care to your customers and meeting your State mandated obligations.
I’ve located a spectrum of resources to help you accomplish this.

Are you committed to wanting a reorganization plan and proposal? I can
help you with this but I think you might have better success with some
alternate approaches to delivering the level of care that you’re eager
to provide. Would this be a suitable answer to your question?

I look forward to working with you.

czh
Answer  
Subject: Re: Organizational Structure
Answered By: bcguide-ga on 31 Dec 2002 03:48 PST
Rated:3 out of 5 stars
 
Hi rags500-ga,

Anyone who has been in a situation with responsibility for regulatory
compliance, but no control over the departments that feed into the
audit findings can appreciate your frustration.

Each department focuses on their primary concern. Often, too often,
compliance with lots of paperwork and confusing regulations, is not
high on anyone's list -- except for the administrator who must face
reviews by external agencies.

The common goal is to provide quality care for the patient, but that
is often lost in the paperwork. Getting cooperation is difficult at
best. With "report cards" being made available to the public based
solely on these findings, the reputation of the intitution and the
staff is dependent on the paperwork getting done. Quality care does
not exist unless it can be documented. Government and insurance
reimbursements depend on these reports. Liability is going to be an
issue in any legal proceedings if your facility is consistently not
meeting regulatory standards. It may seem like silly p[aperwork, but
it means the continued existence of the place where you work. You know
that.

The reality is that it may be more difficult than you realize for the
staff to meet these standards. The government regulations do not take
into account the lack of training, the lack of staff and the lack of
time that make taking care of patients needs a marathon. Meeting
report deadlines just may not seem relevant to the staff member who is
trying to make sure that all of the population is receiving quality
care.

"Improving the Quality Of Long Term Care" (available online) puts it
into these words...
"Given the number of residents who need to have MDS and RAP
assessments completed, it is surprising that there is no information
about what staff time, supervisory oversight, or training mechanisms
are necessary to collect these data accurately. Apparently, nursing
homes are assumed to have both the tangible resources and the
technical expertise necessary for accurate MDS and RAP assessments.
The assumption of "adequate resources" seems particularly tenuous when
the additional resource requirements of assessing resident or family
perceptions of quality are considered. The latter measures are not
covered in the MDS and involve significant technical challenges and
resources that are different from those involved in completing the
MDS, and assessment is only the first step in improving quality and
not even the most labor-intensive step."
http://books.nap.edu/html/improving_long_term/ch7.html

The staff barely has time to provide care - adding reams of paperwork
is just increasing their burden. Getting everyone to feelthat they are
a part of the quality asuurance team is the best way to improve state
inspections. To do that you need to educate them to the reality of
what not meeting standards - on paper - means in the industry today.
No matter how fine the care is, if it's not properly documented it
looks bad.

The Centers for Medicare & Medicaid Services, Nursing Home Quality
Initiative,
http://cms.hhs.gov/providers/nursinghomes/nhi/ has a good overview of
the regulations. The Frequently Asked Questions section may help you
to get others to understand why you are asking for some of the reports
and procedures.

http://www.medqic.org/nursinghomes/measures/index.shtml is another
very good resource for putting the quality measures into terms that
everyone can see as beneficial to both the patient and the
institution.

The American Nurses Association has a very nice continuing ed module
that focuses on the nurses responsibilty under PPS which may also be
helpful in helping staff to understand why the compiance issues are
important to them and the patients - as well as you.
http://www.nursingworld.org/mods/mod90/ltcabs.htm

But even in the event that you do manage to communicate the necessity
for compliance, the staff is overburdened with activities relating to
patient care and forms that need to be completed with specific
information can be left undone or completed improperly.

That brings us to your request for a change in the organizational
structure to allow you to have some formal authority to bring your
facility up to standard before reviewers are knocking on the door.

The answer for many long term care facilities has been to institute a
compliance program with an institutional compliance officer. The
compliance officer normally reports directly to the CEO. The arguments
for doing this before you are compelled to are well stated in
"Introduction to Compliance Programs"
http://www.ppsv.com/issues/intro.htm.

http://www.wsha.org/GoverningBoardManual/qualitymanagement.html is
written for a hospital setting, but the implications of the legal
liability of the Board of Directors for lapses in quality management
apply to your situation as well. This may be your strongest argument
in getting support to strengthen your authority.

Monitoring the Quality of Hospital Care produced by the Center for
Human Services provides a guideline for implementing a successful
quality assurance program.

The model they use is to have the quality assurance administrator
rectuit a team from the relevant departments. The team becomes
responsible for gathering the data and reporting on implementation
issues. The concept is to spread ownership of the monitoring process
to all of the areas involved.

That way, you are not a fussy administrator making unreasonable
demands, you are the team leader who sends your motivated team into
their departments and the quality assurance demands come from internal
sources. As the team leader you would need to have authority to insist
on compliance, but if the team works well, the need to use the
authority should not arise.

"Finding ways to inform and involve staff is also key to success,
since monitoring quality is not the work of a single individual. The
output of quality monitoring may prove useless if staff do not “buy
into” the need for quality measurement. The need to keep all
stakeholders informed cannot be over-emphasized (see the section
'Developing and Implementing a Communication Plan')."
http://www.qaproject.org/PDF/hspcarebook501.pdf

Another approach is described in OASIS and Outcome-Based Quality
Improvement in Home Health Care: Research and Demonstration Findings,
Policy Implications, and Considerations for Future Change for the
three interrelated studies:
The National Medicare Quality Assurance and Improvement Demonstration
The New York State Outcome-Based Quality Improvement Demonstration 
A Project to Assist Home Care Providers to Effectively Use Patient
Outcomes
(February 2002):
"...agencies were encouraged to establish two teams: one to select the
target outcomes (possibly titled the Target Outcome Selection Team)
and another to conduct the other activities (possibly titled the Care
Process Action Team). The Target Outcome Selection Team analyzed the
outcome report and selected the specific outcomes to be investigated.
This team usually included agency administrative and quality
improvement staff. The Care Process Action Team conducted the
investigation and planned implementation activities (with leadership
often provided by a member of the Target Outcome Selection Team).
Agencies were advised to have some staff common to both teams to
ensure continuity of process.

In general, it is desirable for the Care Process Action Team to
include staff directly involved in providing care related to the
target outcome. In small agencies, the Target Outcome Selection Team
and Care Process Action Team may include primarily the same
individuals. In large agencies, there may be one Target Outcome
Selection Team, a Care Process Action Team for the first target
outcome, and another Care Process Action Team for a second target
outcome."
http://cms.hhs.gov/providers/hha/Volume3-SuppDoc7thru9-Feb2002.pdf

Using this double team concept worked well in the demonstration
facilities during the study.

There are plenty of other studies, reports and books on this topic.
You are not alone in the struggle to implement quality management
procedures with an overworked and trimmed down staff who just don't
get why they need to add this to their list of things to do. It's a
tough job, and you do need the support of top management to succeed.
Just don't forget that you also need the support of the staff or it
will just be more frustration for you.

search terms used:
1.nursing home quality control officer
2.problems with compliance quality control issues nursing homes
3.PPS compliance assistance
4.Director of Quality Management nursing home organizational structure
sample diagram
5.Nursing Home Quality Initiative
6.State Surveys to evaluate SNF performance

If you need additional resources, plese post a clarification and I
will respond.

Enjoy your holiday and good luck with compliance. Just hope that the
New Year doesn't bring new regs to add to the paperwork!

bcguide-ga
rags500-ga rated this answer:3 out of 5 stars
It is nice to say that this cannot be changed.  It is evident that the
researcher missed two important points.  Under Flordia law, the SNF
Administrator or held liablity for the facility controlled.  No
exceptions, no excuses.  The Administrator is the one that losses the
license to be an administrator and cannot "earn a living".  The best
solution would be to walk away from the situation.  However, if the
administrator is concerned about patient welfare, this also is not a
answer.

Please note that ACHA refused to rule either way in their lastest
meeting.  This subject was on their agenda, but instructed their
lawyer to contact the questioning administrator directly.

Comments  
Subject: Re: Organizational Structure
From: czh-ga on 31 Dec 2002 13:42 PST
 
Nice job bcguide-ga!

Hello rags500-ga,

Here are some additional resources you might find useful. I found them
during my preliminary research and you might as well use them. Good
luck with bringing about changes in your organization that will make
your job easier and help you to deliver better customer service.

czh

http://www.hin.com/
Healthcare Intelligence Network

http://www.healthcare-info.com/acp.htm
Area Competitor Profiles for
Subacute & Skilled Nursing Facilities
Area Competitor Profiles for Subacute & Skilled Nursing Facilities are
a series of market research reports that provide detailed data on the
individual subacute and skilled nursing facilities in a specific U.S.
metropolitan area. They are designed for use by SNFs, subacute
programs, hospitals, healthcare systems, contract management
companies, consultants and MCOs. Reports are available for all U.S.
market areas. Each report also contains advice on how to interpret and
use the data from a national expert in subacute care and healthcare
market strategy.

http://www.jmaiesi.com/our_services.html
Skilled Nursing Facility Management: 
Let our company provide you with complete management of your health
care facility to produce excellent results.

http://www.aew.com/AEW/Research/ResearchPublications/SH%20Industry%20Ovw.pdf
Understanding Demand – The Aging Process and Housing Options

http://www.snfinfo.com/
Long Term Care Information Supersite

http://www.retirementliving.com/RLccrc.html
Retirement Community and Facility Types

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