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SNF Attending Physicians’ Responsibilities to Patients, Families, Staff, and the Facility
In the past, skilled nursing facilities (SNFs) have invited all community physicians to attend to patients in their facility based on the belief that the attending physicians’ primary role was to provide referrals to the facility. In this environment—where community physicians had attended in the referring hospitals and the fee-for-service system rewarded hospitalizations and SNFs for frequently admitted acute stays (followed by subacute stays)—community physicians were vital to the referral stream. However, with the shift to value-based reimbursement and increasingly regulated environments, the role of the attending physician has dramatically shifted. These new circumstances require attending physicians to work more closely with SNFs to reduce readmissions and legal liability, while adhering to the growing number of regulations.
Physician Responsibilities
By requiring attending physicians to be responsible for certain items, SNFs can meet the challenges of this new environment successfully (Box 1).
To actualize these goals, facilities may wish to provide all attending physicians with a quarterly score in each of these 6 areas on a 1 to 5 scale (5 being the highest). Given how competitive physicians tend to be, in my experience, there is an opportunity to provide this information unblended in such a way that a physician can use it to improve their behavior or, quite frankly, choose to leave the SNF. These 6 areas of focus can be addressed by facilities that aim for more timely care and improved support of staff members.
More Timely Care
Many issues can be resolved or managed more efficiently when care is delivered in a more timely manner. Timely care is especially critical given the increased frailty of SNF patients today in value-based care models. But providing timely care is difficult, as attending physicians have an increasing number of demands on their time. The solution seems to be to add advanced practical nurses, attending physicians who are able to dedicate more time to the facility, and/or vital physician services to SNF teams.
By providing more timely care, several outcomes can be improved, such as faster medical record completion and prompt attendance to patient, family, and staff concerns, which would lead to higher family/patient satisfaction ratings. In addition, certain clinical concerns can be quickly addressed thus preventing avoidable emergency room visits and hospitalizations. Also, with the increased focus in SNFs on falls and antibiotic stewardship, having a clinician available in person to speak directly with staff, to physically hold the complete chart in hand, and to evaluate the patient in person, can alleviate many issues typically encountered due to phone interactions. This timely care ultimately goes toward improving the increasingly important Centers for Medicare & Medicaid Services (CMS) quality measures.
Another component of timely care is the use of the pre-discharge time period to properly prepare patients for caring for themselves at home. As SNFs increase their focus to subacute stays and away from long-term care, careful preparation is required to assure that SNF subacute patients will be successful once they return home. For example, complex treatment regimens that work in an SNF because they are being administered by trained nursing staff may fall apart in the hands of patients and their caregivers. These failures will result in readmissions to the hospital, which can cause penalties.
As a case example, consider a patient with severe chronic obstructive pulmonary disease and type 2 diabetes who is being controlled on nebulized treatments, steroids, and sliding scale insulin. Once back at home, the ability to manage all of this on their own may not be possible. Thus, the short, subacute stay must focus not only on the immediate treatment but also on the preparation through training and care plan adjustment for success in the community. This may require changes in the treatment regimen, training, and providing the actual medication rather than a hand full of prescriptions and printed discharge instructions.
Beyond caring for all residents in a timely manner, there are additional regulatory requirements that mostly revolve around medical records in the form of completion of notes, admissions, especially history and physical exams, and pharmacy consult recommendations. CMS regulations require attending physicians to respond to all pharmacy consults, which includes an explanation as to why recommendations are not being followed.
The scores here include the completion of all medical records in a timely manner. This can be scored by the SNF medical records lead person in assessing each attending on a score of 1 to 5 as well as noting all deficiencies so these can be addressed and trended.
Staff Support
Another important role for attending physicians is the support and education of the entire SNF staff. Today, the independent practice of attending physicians is no longer possible; instead, attendings are vital components of the SNF care team. As such, attendings are needed to lead education of the staff, in both formal and informal ways. Informal instruction may take place through daily interactions, instruction, and observation of staff, while formal presentations can be created around critical areas of concern and presented to the staff as a whole. Leading this education is important for the entire staff, not just those who work the 9-to-5 shift but for those working in the evenings and on weekends as well.
This approach to staff support, interestingly enough, is the center of the Toyota management philosophy, which has 2 foundational principles: continuous improvement and respect for people. Both principles are foundational elements when it comes to support for SNF staff who are directly involved in patient care. The Toyota approach to supporting staff was publicized by Jeffrey Liker, PhD, a professor of industrial engineering at the University of Michigan, through his 2004 book, The Toyota Way.1
Continuous Improvement
Dr Liker characterizes the Toyota way as “a system designed to provide the tools for people to continually improve their work.” According to Dr Liker, Toyota’s management philosophy can be broken into 4 main principles (Box 2).
While the Toyota culture is obviously aimed at producing great cars, the health care field could learn to apply its management philosophy to care settings and facilities to produce better health care outcomes. The application of this management model is especially relevant as SNFs are increasingly being driven to produce outcomes that they are then being held accountable for, such as reductions in hospital readmissions, emergency room use, and an ever growing list of CMS quality measures. This is only achievable through a supported workforce.
Respect for People
The second area of focus in the Toyota culture is respect for people. Although it is often surmised that high staff turnover in health care is caused by low wages, it is, in my opinion, the feeling of being respected much more than money that drives staff to remain in a position. Attending physicians can play an important role in demonstrating respect to their staff. This philosophy has also been discussed in 2 recent books, Shola Richards’ Making Work Work2 and Duke University professor Dan Ariely’s Payoff: The Hidden Logic That Shapes Our Motivation.3 Both authors found that providing respect is best delivered to staff through these 3 evidence-based strategies4:
1. Choose prizes, not cash
In a recently aired NPR podcast,5 Nobel prize winner and behavioral economist Richard Thaler explained why organization leaders should choose to reward staff with gifts or experiences rather than cash. For example, rather than giving them a $500 bonus, he suggests giving them a $500 vacation. When people receive the vacation, he said, they report being significantly happier than when receiving the cash. This is because when we receive cash, we are torn between saving and spending it. With a vacation, however, we can enjoy the gift without any guilt. Whether it is a gift or a team outing, spend extra effort identifying a noncash way to show your employees that you care. Although it seems counterintuitive, they will be happier for it.
2. Say “thank you”
According to psychology professor Robert Emmons, giving thanks at work should be mandatory.6 In addition to strengthening teams and corporate culture, gratitude motivates employees more than money. In one study, GlassDoor researchers found that 70% of employees would feel better about the effort they put in if they were thanked more regularly by their boss.7 In another Wharton experiment, researchers found that when fundraisers were given a pep talk by a director who thanked them for their efforts, they made 50% more fundraising calls than those who did not receive a pep talk.8 There are a number of ways you can thank your employees for the same effect. Simply thank them in the hall or write them a personal thank you card. At a larger scale, you might thank specific individuals in a company meeting or email.
3. Give compliments
In an experiment exploring employee motivation, behavioral economist Dan Ariely and colleagues compared how different incentives affected employee performance.9 On the first day of the experiment, workers were given either $30, a voucher for a pizza, or a “Well Done!” compliment from their boss. The voucher and compliment were equally effective in increasing performance, while the cash was less successful. As the week went on, the monetary reward actually led to a decrease in employee performance. It had a worse effect than giving employees no incentive at all. Based on this experiment, leaders may be best served to find a meaningful way to acknowledge staff. One way might be a staff recognition program where specific employees and the work they have done is highlighted.
Leaders in SNFs can learn from the management philosophy of Toyota, which, as demonstrated, is supported by numerous other experts and studies. Aiming for continuous improvement and sustained demonstrations of respect for staff are critical components of a successful SNF. Without an engaged staff in SNFs, all of the outcomes that physicians are being held accountable for will come up short, and, most importantly, the care received by SNF residents will be impacted as well.
Conclusion
As SNFs continue to optimize and adapt their processes in the shift to value-based care models, some leaders will look to the employment of attending physicians or nurse practitioners in an effort to improve their delivery of care and reduce their liability. An alternative to investing in hiring staff may be to simply hold their current and additional attending physicians accountable for what these SNFs need. These needs include working more closely with patients, families, and staff as well as improving delivery of their clinical services—all in an effort to improve care outcomes and reduce liability. But holding existing attending physicians accountable may require re-training to assure the proper skill sets needed for success. Those SNFs with responsive and responsible attending staff will find themselves succeeding in value-based care as well as reducing their liabilities.
References
1. Liker JK. The Toyota Way. Madison, WI: McGraw Hill; 2004.
2. Richards S. Making Work Work. Edison, NJ: Sterling Ethos; 2016.
3. Ariely D. Payoff: The Hidden Logic That Shapes Our Motivations. New York, NY: Simon & Schuster; 2016.
4. Venkatraman R. 3 simple ways to show appreciation for your employees no money needed. Inc.com website. https://www.inc.com/rohini-venkatraman/3-simple-ways-to-show-appreciation-for-your-employees-no-money-needed.html. Published October 31, 2017. Accessed May 24, 2018.
5. Predictably unpredictable: why we don’t act like we should [podcast]. National Public Radio Inc. https://www.npr.org/templates/transcript/transcript.php?storyId=462386252. Published January 12, 2016. Accessed May 24, 2018.
6. Vozza S. The science of gratitude and why it’s important in your workplace. FastCompany.com website. https://www.fastcompany.com/40575835/let-this-brain-scientist-optimize-your-morning-routine. Published November 24, 2016. Accessed May 24, 2018.
7. Glassdoor Team. Employees to retain half of their employees longer if bosses showed more appreciation; Glassdoor Survey. Glassdoor website. https://www.glassdoor.com/employers/blog/employers-to-retain-half-of-their-employees-longer-if-bosses-showed-more-appreciation-glassdoor-survey/. Published November 13, 2013. Accessed May 24, 2018.
8. Grant AM, Gino F. A little thanks goes a long way: Explaining why gratitude expressions motivate prosocial behavior. J Pers Soc Psychol. 2010;98(6):946-955.
9. Eisenberg R. What workers crave more than money. Forbes. https://www.forbes.com/sites/nextavenue/2016/09/27/what-workers-crave-more-than-money/#6ba6a3c53150. Published September 27, 2016. Accessed May 24, 2018.
10. TechTarget. Seven wastes. Tech Target website. https://whatis.techtarget.com/definition/seven-wastes. Updated March 2009. Accessed May 24, 2018.
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