Good communication, a focus on patient care, and an efficient use of staff all contribute to the success of decentralized departments.

Health care has been living in the shadow of reengineering for a decade now. There are many models of redesign that have been recommended and tried, but decentralization was the form of redesign that most consultants recommended for respiratory care departments. Perhaps as a result of the new budgetary pressures from the Balanced Budget Act of 1997, the concept of decentralizing respiratory departments seems to be coming to the forefont once again.

Most fully decentralized models failed, or were aborted before full implementation. Of the various models of decentralization, the one that has had the most, if limited, success, is a modest decentralization in which a core central department remained, but the respiratory staff of specialty units or specialty functions were separated to report directly to the nursing unit. This decentralization model will be addressed in this article. The appropriateness of the strategies in this article will depend on specifics of the situation, including the size of the facility, distance between various decentralized units, and staff configuration.

I am personally not an advocate of decentralization. The provision of respiratory care is already a decentralized venture, and maintaining multiple respiratory operations (which is what decentralization really boils down to) raises many problems and inefficiencies of its own. However, whether you are an advocate of redesign and decentralization or not, you may have to work in a decentralized model. The Respiratory Department at North Mississippi Medical Center remains administratively united but has some decentralization characteristics: designated teams of therapists are assigned to the critical care units, emergency department, and respiratory specialty unit on an ongoing basis. The Women’s Hospital, a separate facility 1 mile from the Main Unit, has a separate, designated respiratory staff. Baldwyn Nursing Facility, also administratively part of the Main Unit but located 20 miles away, has a separate respiratory staff. But our facility uses many of the concepts presented in this article to retain the best of the centralized model while working in a decentralized way when it benefits the system and the patients.

Based on input from various individuals who have lived with full decentralization, as well as my experience with functional decentralization, the key to making a decentralization model work is recognizing its shortcomings and planning to avoid them. Some of the potential and common pitfalls of decentralization are the loss of consistent goals from unit to unit, divergence of procedures and clinical practice, loss of standardization of supplies and equipment, the requirement of multiple pools of relief personnel, and the fragmentation of respiratory staff education and competency assessment. Additionally, elimination of opportunity for ongoing experience in various care areas can lead to the loss of multiunit skills, reducing staffing flexibility. Many therapists want the opportunity to vary their assigned areas, and the loss of this opportunity can lead to staff dissatisfaction and turnover. In the experience of some managers involved with decentralization, therapists suffered a loss of professional identity and camaraderie, leading to staff disaffection and turnover.

All of these issues can impinge on envisioned savings from redesign. More important, they can detract from patient care. Experience indicates that, to have the greatest chance at success, a decentralization project can avoid many of these problems by retaining the best characteristics of centralized department design. High-quality and timely communications, professional collaboration, collaboration on supply and equipment issues, and maintenance of flexibility and cross-unit backup are all features of centralized departments that benefit a decentralized model.

To maintain communications, professional identity, and consistency in goals and purpose, the decentralized respiratory service often generates a “virtual department” through informal collaboration. Issues of supply use, equipment issues, general practice questions, and unit-to-unit cooperation can be resolved through this device. Eventually, clinical professionals of like background will want and need cross-unit interaction. It is best to support this development and use it to the betterment of both the staff and the facility.

One costly downfall of decentralization can be the loss of standardization of supplies and equipment. Duplicate inventory for various units, fragmentation of purchasing volumes (and subsequent loss of purchasing leverage), and equipment and supply variance, which can cause staff competency issues, are all expensive results of nonstandardization. This is especially true of capital equipment selection and purchases. A mechanism through which the components of the respiratory service, from various separated units as well as the core department, can consider and agree on standardized supplies and equipment should be established. The “virtual department” mentioned earlier has been used by some as the mechanism for this collaboration.

Continuing education, annual competency evaluations, and instruction in the operation of new equipment can be difficult and inefficient, as well as costly, if carried out unit by unit. Many decentralized operations left these tasks to the core department from the outset; many that did not, return these functions to the core department after experiencing the alternative. If the other suggestions in this article have been applied, there will be readily available backup staff to flex staffing as necessary to get respiratory staff from all units through these processes.

Good communication must be maintained among the various components of a decentralized respiratory service if patients are to effectively move from place to place. However accomplished, this communication must provide seamless transitions of patients from unit to unit or from unit to the core department. A well-designed and managed manual system can effectively handle many of these needs, but manually getting the information from place to place in a timely and complete manner can be difficult. Ideally, a patient management system specific to respiratory services would be supported and provided by a computer-based system. Such a system should have safeguards that assure that no patients are “lost” or accidentally discontinued during or as a result of transfer. This can be accomplished by coordinating patient information and order notification at both the discharging and receiving units. Such systems are expensive; however, they can prove worth their cost if they increase the efficiency of the therapists and avoid patient dissatisfaction or negative outcomes due to incorrect or missed care.

All of these issues lay the foundation for the most important problem: efficient use of staff. The most expensive component of a hospital is its staff. Decentralization advocates said that elimination of staff travel time would increase efficiency. The validity of this concept is uncertain, which lies at the heart of three potential problems in decentralization:

1) Many facilities investigating decentralization found that more therapists were required to cover their facilities in a decentralized model. This realization ended numerous decentralization projects.

2) The role of respiratory therapists in specialty units must be well conceived and implemented to avoid excessive downtime or to avoid having highly skilled and highly paid therapists doing busy work better assigned to lower-skilled personnel. In some institutions, respiratory therapists became glorified nursing assistants once the model was implemented, costing more for the same work and alienating many of the best therapists.

3) Any features of the decentralization model that decrease flexibility in the use of personnel need to be evaluated and avoided, for this can impose great inefficiency. If each specialty unit separates completely from the core department, specialty units can be left with no therapists competent to fill in for vacations or illness. Some facilities may successfully adopt the philosophy that a nurse can cover a therapist or a therapist can cover a nurse, allowing for complete internal coverage. However, this solution seems in conflict with today’s goal of optimally matching skill mix to need.

Through maintenance of a core department that retains a rotation relationship with the specialty units, the cross-unit skills of a team of therapists can be maintained, providing readily available and competent relief therapists without multiple “as needed” pools. If the goals of the respiratory therapists in the specialty units are consistent from unit to unit and with the core department, if clinical practice is consistent, and the equipment standardized, staff can continue to be shifted as necessary for optimum coverage and efficiency.

Finally, the cost of therapist dissatisfaction must not be overlooked. Dissatisfied therapists leave, and turnover is very expensive. Some human resource professionals say the cost of recruiting, interviewing, hiring, and orienting a new employee may be as high as $30,000. A few extra resignations can have a significant impact on the bottom line.

If the key to successful decentralization is maintaining much of the centralized model, one may ask, “Why decentralize?” It may be that specifics of a facility lend themselves to decentralization. It may simply be that consultants or administrators have mandated it. If a decentralization project is in your future, addressing the points in this article may make it viable. If you are struggling in a decentralized model now, adapting some of these strategies may help. No single model is the best for every facility or circumstance. Clearly, some degree of decentralization may be beneficial, but complete decentralization generally creates as many issues as it solves.

Maintain consistency of practice and purpose, maintain common respiratory service goals across units, and build mechanisms that encourage rather than impede collaboration and standardization. Regardless of what model you are operating in, these strategies will serve your facility, your staff, and your patients well.

Larry Conway, RRT, is director of respiratory, neuro, and sleep disorder services at North Mississippi Medical Center, Tupelo, Miss.