The Number One Management Problem in Home Care

CARING Magazine August 2009
Dr. Robert Fazzi, Managing Partner

Kay Wright is a home care veteran and one of home care’s true national leaders. Many view her as a matriarch and a mentor. Anyone who has met her quickly realizes that they are in the presences of a truly passionate, talented, confident leader, a person who loves home care and deeply believes in its mission and efficacy.

An RN with an MBA, she has worked in the field for nearly forty years. She is a renowned expert in the management of home care agencies and systems having worked in a number of states and served as director of agencies of various sizes including serving as President of one of the largest free-standing agencies in New England. She has worked with non-profit and profit agencies including free-standing agencies, hospital based agencies and agencies that are part of large systems.

More recently, she has moved from managing agencies to consulting with agencies. She has conducted operational reviews on dozens and dozens of agencies and has overseen consulting teams who have done similar reviews in far more agencies. Together, her teams have conducted operational reviews in every region of the country and for just about every size and type of agency. Kay knows home care and she knows management.

There is one other thing about Kay Wright: she has opinions, strong educated opinions, on why some agencies excel and others fail. She would sum it up in one word: accountability or better yet, the lack of managers’ ability to hold their subordinates accountable.

Accountability: Home Care's Biggest Management Problem

Without accountability, there is no success. In home care as well as in any other business or endeavor, if commitments are not kept, the effort fails.

Here is a simple example – productivity. Agencies often build their budget around clinical staff achieving a certain level of productivity, i.e. an average of 5.0 visits/day. If it cost $800/day for a nurse to be in the field (salary, benefits, overhead, etc.), then the cost per visit is $160 ($800/5 visits = $160.00). If the nurses only average 4.5 visits, then the cost per visit would be higher - $177.77/visit. If the agency averages 20 visits/patient, the cost of patient at $177.77 would be $3,555.40 versus $3,200 for the $160/visit. And if you are seeing 1,000 patients each year, you can quickly see how significant of a problem this would be.

But, this is not an article about productivity; it is about accountability. If this were your agency and this had been going on for over a year, where is the problem? It is not the staff! Why? Because the staff have been performing at a 4.5 productivity level for over a year and there has been no consequence. They have learned that 5.0 is not a real number and that 4.5 (other than a few weak pleas by managers) is the acceptable number. There is no accountability!

Where Is the Problem?

The accountability issue could be related to productivity. It could also be related to OASIS accuracy or customer service or timeliness and completeness of paperwork or a number of other key performance indicators.

If the problem is not staff, then where is it? It is the supervisor for not holding their staff accountable. But wait, it doesn’t stop here. If this has been going on for a year and the supervisor has not dealt with it, there is another problem – the Clinical Director who has not held the supervisor accountable.

And guess what? If the Clinical Director has not held the supervisor accountable, then there is one other person we need to look at, the person ultimately responsible for modeling and ensuring that the lines of authority and the accountability systems work throughout the agency. Who might that person be? The agency Administrator who has not held her Clinical Director accountable!

Accountability: The Problem and the Answer

After nearly four decades of service and management and after nearly 100 operational reviews, Kay Wright has something else to say. “There is an answer, a simple answer that works and that can quickly become the foundation for an agency’s overall management and performance system.” The answer: “Outcome Management,” a management system that is simple, clear and provides everyone from supervisors to the agency leader with a clear set of measures and principles for which they can hold their subordinates easily accountable. Part II will provide the key components of this management system.

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About the Authors:

Dr. Robert Fazzi is the Founder and Managing Partner Fazzi Associates. He is an author, researcher and consultant who has provided consultation and training to the home care and hospice community for over thirty years.