Southside Hospital developed an assessor position to improve patient outcomes and shorten length of stay.

Two years ago, we went looking for a better way to assess patients in the Respiratory Care Department at Southside Hospital, Bay Shore, NY. It started with a proposal to create a new position called “respiratory care assessor.” This person would collect pertinent information to reduce the length of patient stays and meet the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements for patient assessment and reassessment.

After input from the medical board was given, we received approval to develop the new position as a pilot program. Ten months later, the assessor had collected and analyzed enough data to make a considerable impact on the utilization of respiratory care services. Shortly after that, in February 1999, the hospital agreed to fund the position on a permanent, 20-hours-per-week basis.

History and Mission Determined Need
Southside is a not-for-profit, 400-plus-bed community hospital sponsored by the North Shore—Long Island Jewish Health System. Our Respiratory Care Department is a clinical teaching site for the State University of New York at Stony Brook, School of Health Technology and Management. We provide care 24 hours a day, 7 days a week, to a large population of Medicaid, underinsured, and self-pay patients.

Southside Hospital
• Southside is a sponsored hospital of the Northshore—Long Island Jewish Health System.
• It is a 400-plus-bed community hospital.
• Southside Hospital’s Respiratory Care Department is a clinical teaching site for the State University of New York at Stony Brook, School of Health Technology and Management, Respiratory Care Program.

Providing this care is a core value of our mission to serve people in the community, regardless of their ability to pay. As noble as it may sound, this philosophy requires constant innovation to survive. We hoped that creating the assessor position would help us discover new and creative ways to meet our goals.

More than a decade ago, we believed that an RCP’s skills should be used for more than just performing tasks. If allowed to make decisions about direct patient care, RCPs could bring added value. With this possibility in mind, the Respiratory Care Department developed mandatory protocols more than 10 years ago that were applied to most patients receiving oxygen and inhaled medication therapies. Four years ago, we offered therapist-driven protocols as an option to the medical staff. Respect from the medical board and medical staff was vital in gaining approval of these programs. From this strong foundation, an assessor position was the next natural step.

Assessor Job Duties
When the pilot program started in May 1998, we had an idea of what we wanted, but it was not until we brainstormed as a group that we thought of all the potential benefits. We determined that the activities of a respiratory care assessor had to be of a multidisciplinary nature with an emphasis on communication with other caregivers and our own staff. From this, we developed an initial job description.

Job Duties
• tracking all patients once they enter the respiratory care service and establishing a reassessment schedule for each patient during their admission;
• making changes to the respiratory therapy care plan based on the patient’s changing clinical status as allowed by protocol or by contacting the physician for a change in order;
•documenting changes to the patient’s care plan in the medical record and communicating these changes to other RCPs and caregivers by participating in interdisciplinary team meetings; and
• participating in the department’s performance improvement process by gathering data to monitor the delivery and method of respiratory therapy.

• National Board of Respiratory Care registration;
• graduating from a recognized school of respiratory therapy with a minimum of a 2-year degree;
• 5 years of clinical experience;
• demonstrating consistent performance and decision-making when applying department protocols; and
• possessing excellent communication skills.

An RCP from the staff, Darlene Caico, RRT, met the above requirements and volunteered to help develop and initiate the pilot program. A multidisciplinary team helped Caico develop the processes she would use on the job.

With the exception of critical care and the emergency department, Caico reassesses patients on the respiratory care service every Monday, Wednesday, and Friday, and varies her hours on those days to meet the needs of the program. She collects data that are used as part of our performance improvement process for evaluating the continued effectiveness of the assessor position. She distributes patient surveys that provide an overall customer satisfaction rating for the Respiratory Care Department.

Statistical Data
The most important justification for the position is improving patient outcomes and compiling more reliable outcomes data. Every patient interaction is an opportunity to modify the respiratory care plan based on the patient’s changing clinical status.

Every day that patients were seen produced new data that increased or decreased treatments depending on the results of individual reassessments. We compiled this data into monthly reports during the pilot program to determine if we were, in fact, improving patient care by addressing inappropriate therapy and utilization of services.

The respiratory care assessor pilot program resulted in:
• an estimated annual net savings of $20,500;
• a 9% decrease in overall patient length of stay under respiratory care service;
• a decrease in frequency of therapy by 17%;
• increased therapy by 6%;
• influenced mode of therapy changes by 6%; and
• a decrease in oxygen therapy by 13% through our oxygen therapy protocol.

The pilot study showed that the respiratory care assessor made 3,424 patient visits, averaging 342 patient visits per month, while working Mondays, Wednesdays, and Fridays for 5 hours. Further analysis showed an average of 28.5 patient visits per day at 10.5 minutes for each visit. We used the following terms in the study:
• Patient visits—the number of patient visits by the respiratory care assessor per week. The visits were totaled at the end of each month;
• Mode of therapy changed—changes the assessor made as indicated by the patient clinical assessment. Did not reflect a decrease or increase in frequency in all cases;
• Increase or decrease in frequency—when a patient is assessed, and it is determined by clinical evaluation that an increase or decrease in frequency of therapy is required, the assessor will contact the physician to discuss the need for the change. If the patient is on protocol, therapy is changed as permitted by protocol;
• Patient discharged from service—an indicator used to determine patients that have been discharged from respiratory care services, but not necessarily from the hospital;
• Therapy turned over to nursing—this term specifically addresses metered-dose inhalers. Once the patient was provided with education about using this device and was able to demonstrate proficiency, responsibility for future treatments was turned over to nursing.
• Oxygen therapy D/C as per protocol—this refers to oxygen therapy that has been discontinued as per protocol by the respiratory care assessor.

Additional Benefits
We originally designed the program to maintain and achieve the JCAHO standards for patient care assessment. However, we found additional benefits over and above our original plan. The assessor helped decrease the time that staff spent waiting for physicians to call back concerning patient orders. This allowed more time for patient care.

Other hospitals in the 13-hospital Northshore—Long Island Jewish Health System are watching our program and letting us work out any problems. For example, there are economies of scale to having one assessor, but we must make sure that we are not putting too much specialization in one individual’s position at the exclusion of the other therapists. From the physician end, we must continue to ensure that our link with the medical staff is solid.

Will adding additional assessment hours or days further enhance our services utilization? This will be the next issue to examine as our assessor program continues. Increasing the position to 371¼2 hours a week is a possibility, but we must always contend with the problem of limited resources.

So far, the assessor program has proven to be a nice link in our overall plan of using protocols to improve care for our patients. As the data show (see Figure 1, page 88), an assessor can have a substantial impact on patient outcomes while providing value to the organization. For many patients, these acts (collecting data and distributing surveys) have the intangible effect of improving patient morale by showing that we care enough to take the time to improve overall care.

Harold Lanni, MBA, RRT, is director of respiratory care, and Stephen Smith, MPA, RRT, is assistant director of respiratory care at Southside Hospital, Bay Shore, NY.