Center Administrator (Moi)

[Mr. B]

Please see my 1st post on the "introduction" section.





EDITED: First Post reads:
"Where do I start? I am the administrator for a home health company. Our customers, clients & patients have all asked the owner, a pastor, to develop an independent patient-centered center. We realized that over 80% of dialysis centers are owned by large companies. Large companies NEVER deliver care thinking patient first--no matter what they say. I am on this forum to hear from you. I want to know what patients want. In our center, you guys will have more input than most. So let me have it!"

Please do not ask our members to jump around looking for your posts. If you have something to say then type it out. Thanks.

Sluff/ Admin

[Mr. B]

Oops. Sorry. I am falling into the "Stupid Center Administrator" catagory already! And we haven't opened our doors yet! Apologies.

I have a question. Which (brand name) center dialysis machine do you prefer & why?

[Sluff]

Oops. Sorry. I am falling into the "Stupid Center Administrator" catagory already! And we haven't opened our doors yet! Apologies.

I have a question. Which (brand name) center dialysis machine do you prefer & why?

It's ok Mr.B 

I can't answer that but you will recieve many replies I'm sure.

[okarol]

I am wondering if you will offer only in-center hemo, or if home hemo will also be something your center will support. Will you techs be trained and certified before being put on the floor with patients? How many hemo stations will you provide? Sorry, I have more questions than answers for you!

[Mr. B]

okarol,

We will most definitely support home hemo. Home care is a huge part of what we do already. Adding hemo should be a seamless event once the hemo RN's are trained in home care (not just dialysis, we want them to be able to take a more holistic approach to their home care).

Regarding the techs: regulations are very specific as to who can do what in a center. If you feel you have uncertified/unqualified people at your center performing tasks outside the scope of their position, be specific & talk to the management. If that doesn't work, get the 800# for your state's health department & drop a dime.

On the number of hemo stations. We started off with 10-15. Then, we ran the numbers. It costs about the same to build a 10 station unit as it does a 20 station unit. So we upped it to 20. That said, I have assurances from the owner that staffing would also double. Assuming full capacity, my plan calls for a nurse manager & 2 RN's on per shift.

Per shift you ask? We intend on being open early in the morning until late at night. A lot of our dialysis home care patients complain about limited hours. We'll try to fix that.

Sound okay?

A little long on the answer I know, okarol, sorry, I am having lunch!

[Mr. B]

I have a question. I have read a lot of entries on this board & I am hearing folks talk about a myriad of symptoms associated with dialysis. Does anyone get a palliative consult by a doc that knows something about symptom control?

[willieandwinnie]

Mr. B.
Where my husband did dialysis (he is now 4 weeks post transplant), they treated all patients the same. One size fits all, the drier the better.  It would of been so nice to get individual care and treatment. All patients are not the same. We went on home hemo as soon as we could and that worked very well for us. The clinic wasn't very encouraging for home hemo and my husband was their only patient. I believe for profit clinics let the profits over-ride patient first care. That's my  worth. I think I'll enjoy following this thread.

willieandwinnie

[BigSky]

okarol,

 Assuming full capacity, my plan calls for a nurse manager & 2 RN's on per shift.

That all the RN's???

[Mr. B]

BigSky,

Please tell me how many RN's I need. I am serious. Remember what I said, we want to be patient-centered. I will adjust accordingly. If you look at staffing web sites, most centers run 1 RN per 15 patients. That is crazy. I plan my hours of operation to be something like 3am to 11 pm & I will adjust as needed. The question is what is needed. That's at this forum I need to know what is needed. Let me ask. If I have 10 guests at 3am, how many RN's do I need? (Oh & our patients will be treated like guests. If I hear about any staff being disrespectful or short, they're gone. As a manager, that is an easy expectation. You let them know this during the interview, orientation, etc. Plus we will pay approx. 17% above the market.)

[Meinuk]

Mr. B,

Not to be disrespectful, but do you have a medical director on board?  Have you been working with a nephrologist?  I gather from your previous posts that you are still in fact finding stages, dialyzors can give your their wish list, but there are some very practical issues at hand.  Have you visited a Dialysis unit?  You will need to reevaluate your staff, cost effectiveness between RNs, LPNs and Techs, as well as policies & procedures not to mention what all of these decisions would have on your insurance coverage.  All of this will be predicated by the services that your center provides.  CAPD, CCPD, in center,nocturnal, home hemo etc.

I am all for the holistic approach and palliative care for dialyzors and I admire the effort, but there are some cold hard medical/financial truths that need to be factored into any business plan.  You are dealing with life and death here. 

That being said, dialyzor education should always be a priority.  If you can get a like minded nephrologist(s) & endocrinologist (s) on board; along with a staff of dietitions ,nurses & techs, and the dreaded social workers, train everyone to work as a team, with the dialyzor included on that health care team, then you have a chance to hit a home run.  It ain't easy.

[Mr. B]

Meinuk,

Great concerns & questions. Actually we have 2 nephs working with us. One is a "dialysis doctor" the other is a referring neph. They are not related in their practices. The dialysis doc is our medical director.

I have visited several centers & I have not been impressed. A row of chairs. I am thinking that I need to set up a "pod" center where like situated guests are adjacent. Why would you place a geriatric dementia patient next to a young dreadfully frightened patient that likes pop music, computers & flirting?

Insurance/Medicare. I know that animal. There is a lot of good news if you have a good admissions person & social worker. 

Meinuk, please trust me on the business plan with regard to palliative care. We don't have to pay for that service because Medicare part "B" covers doctors visits. We don't bill them, we refer to them. I don't understand why palliative care is ignored. I am not a doctor (I am a chemist) but it seems to me that a lot of post & pre dialysis symptoms can be resolved. I don't know, but I will look into it.

Staffing. Core positions are given to us by law. I add a few more out of common sense. I am a big fan of social workers. Don't laugh. In most centers they an arm of the marketing department. Well, I don't, & will never have, a marketing department. They going to be there to get things like palliative care, work hard on financial & family issues. I have added (in my pro forma budget) a spiritual coordinator & activities coordinator. We're going to bring families into this. Also one of my social workers will be tasked with assembling a cadre of volunteers.

In sum. We are not in this for the money. We didn't take a vow of poverty, but please understand that chain centers send up to 30% of their cash flow to a corporate entity. We intend on taking the same amount of cash flow to spend it on our guests & our staff.

I have run a home health agency for a long time with these basic philosophies & my boss (owner) has never been displeased. I need to hear from you more.

Very kind personal regards.

[Meinuk]

Mr. B.  - Now that was a post. 

I admire your ambitions.  I  think that surveying actual dialyzors is a great idea and welcome you to the boards.

I am just one of many - there are many diverse and helpful people here at IHD, factoring in their observations and experience can only help.  I hope that they serve your plan well, and wish you the best.

Regards,

Anna

[kitkatz]

Hire nice people.

[boxman55]

Where is this going to be. As far as in-center machines all the techs and nurses like the Fresanius (sp?) over the baxter,  also look into heated chairs, cable tv, maybe Wi-Fi make sure there is enough duplex's for DVD players and such close to the chair. If people are facing the afternoon sun have good blinds. Four chairs in a pod works pretty good for some privacy.....Boxman

[Mr. B]

boxman, kitkatz, Meinuk,

I am leaning toward the "F" machines from talking to people. I have noted the heated chairs & other personal tech stuff to satisfy. Please know that I am making a list from suggestions off this board. When I meet (yet again) with the constrution engineer in a few weeks, ALL of these type of things that are mentioned on the board will be on the table.

Hiring nice people. I am a nice guy, but I have zero tolerance for rude staff. I tell people that I can be their facilitator, coach, advocate. But don't make me be your boss. Oh, and show up on time, refreshed & ready to work. You know what's (no so) funny? I have met so many rude administrators! Not just rude dialysis administrators. Being out there in the medical community in north Texas for about 10 years, I have meet some nutzos. Nursing home administrators rank right up there Attila the Hun. Evil clowns. When an administrator acts like that, it filters down to the staff instantly. kitkatz, that is a long answer, but you guys have been so helpful & warm I thought your suggestion warranted a more complete comment. 

Now it's Texas OU weekend here, so I have to get ready for my watch party. Hook 'em horns!

[Bill Peckham]

Include people with kidney disease in your governance, including at least one person who dialyzes through your center on your board (we have two dialyzors on the board and three with a transplant (xdialyzors)). My provider has a chaplain in addition to very experienced Social Workers - there is non-social worker staff who deal with transportation and finance, freeing the SW to do social work.

Staff are the key - their training and retention is a hard nut to crack. Good luck with that. What is your projected payor breakdown - Medicare/Medicaid/EGHP?

As Meinuk said dialyzor education - especially continuing education - is key and is very difficult to pull off. Reaching a dialyzor's circle of support is important and difficult. On Saturday October 27th the Northwest Kidney Centers will host the third annual Family Health & Kidney Expo at Qwest Field (Seahawk Stadium) in Seattle. This year we are expecting 1,700 people including 200 NKC dialyzors. We've had the goal of 200 dialyzors every year and have come up short every year - 118 in 2005; 114 in 2006. 200 represents about 15% of the NKC census. Come on out and do the Expo - I'll personally tour you through one of our centers on Monday after the dust settles.

[KT0930]

You mentioned seating like patients together. Carry this over to the home dialyzors, as long as you have a few who are interested. Let them meet, give each other support & advice that the nurses just wouldn't have. Something like a person-to-person IHD. I love doing PD at home and not having to go to clinic all the time, but I feel like I'm all alone sometimes with this thing, because I don't know any other ESRD patients aside from those here at IHD.

[kitkatz]

For God's sake make you staff be aware of patient's charts and conditions.  Nothing makes me more mad when a nurse comes over to give me a TB test and does not know I can't get one due to a positive one a year ago! Then they get huffy woth me about it.  Well sure as shit I did not try to make life hard for the nurse.  Read the damned chart one in a while. Listen to your patients when they talk about how they feel.

[Bill Peckham]

Mr. B do you subscribe to Nephrology News & Issues? There was an interesting article in the September issue re: nurse turnover. (PDF link)
http://www.nephronline.com/nephnews/images/stories/Magazine/September/2007/nursing_nni0907.pdf
Some units reported 150% turnover! Flat screen TVs can't make up for that.

[Mr. B]

Happy Monday all!

Bill, I can't make it to the expo on this short of notice. Dang it. But if anybody knows of any groups meeting from say, December on, please let me know.

And I have downloaded & printed the article in the link you posted. I agree with most of that article. One of the problems with nurses is folks like me. Not me personally, but administrators move from job to job so often. Administrator turnover is a problem in keeping a happy staff. Corporate-type administrators are under ridiculous financial pressures that have little to do with care. Plus they have to deal with staff. And patients. Some people let it get to them & instead of being creative managers, they become these captain Bly people.

With regard to reimbursement, I hate to leave what seems like a half answer or be a smarty pants, but payor mix is determined by patient mix. However, I am, for budgeting purposes, assuming 100% of the medicare composite rate.

KTO 930, Home group dialysis? Or is Group home dialysis? I will put this on my home program list & talk to my social worker about it. Whenever like minded people are, like minded people seem to thrive. But I am not hiring a receptionist to sit in your foyer! But what would be cool, assuming you all dialyzed roughly at the same time, is to schedule the nurse visit. Or maybe not. Maybe you don't want to see a nurse during that time. I don't know. (I know in home care & hospice, the less "medical" we make their experience, the better things go. Having a nurse there may just remind you of a dialysis center).

Dialyzor on the board. Check.

kitkatz, trust me, I have managed nurses for some time now. It can be like herding cats. What you ask about is a professional nursing practice subject. I know many wonderful nurses, but I also know the huffiness of which you speak. I have realized that they don't train nurses about what professionalism means. It seems they, did however, train them to gossip & create mischief! Most nurses don't work well under pressure & tend to fly off the handle easily or get bitchy if challenged, just keep that in mind. But, it's the attitude I don't like. There is no reason for a nurse to be huffy, period. Complain to her/his boss.   

       

[Mr. B]

Bill, I reread the article. Some questions to keeping staff & keeping them happy really don't require complex solutions, formulas, focus groups, etc.

We are a purposely small healthcare company. We can afford more for our patients & staff because there is no giant corporate entity sucking the money of our spreadsheet. That helps keep staff. Mainly because nurses tend to be advocates. And I indulge them to ridiculous levels. If you let them take more responsibility, that works too. I set up a library were nurses were tasked with reading a academic articles & presenting them at an inservice. Anything in medicine. You may not think that's anything, but they are not used to reading about medicine & it really excites most of them. Keeping folks involved. Oh, I have them evaluate management. My DONS bonuses is tied to their evaluations. My mangers evaluate me and so on. My turnover this year is low. I call it a retention level. I have retained 92% of my nurses from the beginning of the year. My retention rate last year was 83%. We are a differant little company. I tend to hire runts. I'll take someone that says they want to do something more than impressing me with their degrees and all of the amazing things they can do. These are just a few ways to keep staff, but basically it's keeping it real, being genuine and caring and most importantly, not having a corporate filter. Pun intended. Oh, did I mention laughing your ass off as much as possible?

[Zach]

Mr. B.,

Will you be offering a self-care section at your dialysis center?

Also, will you be using high-flux or low-flux dialyzers?  Single use or reuse?

Thanks,
--Zach

[Adam_W]

You beat me to it, Zach. I was about to ask about self-care as well. One of the things I hated most about my old centre is being FORCED to sit there like a good li'l patient and not have any part of my own treatment. I know that centres have to be certified by Medicare to offer self-care, but it still sucked @$$. There were times, however when my alarm would go off, no one would come to reset it, and I would say "to HELL with this, I'm not going to sit here and let my blood clot in the lines because this place is so damned bloody short-staffed for someone to come over and press my reset button", so I would correct the problem myself, clear the alarm, and resume my treatment. I got reprimanded by some of the nurses a couple times for "touching the machine" but I told them straight up that I didn't care. After that went on for a while, most of the techs said to me privately that they won't stop me from handling my alarms, because it makes me more comfortable, and it makes their jobs easier. OK, enough "lack of self-care" ranting, I'm happily at home with my little NxStage machine, and that's all in the past.

Adam

[goofynina]

Good for you Adam, i love stories where the patient ends up getting the upper hand, especially if they have to fight for it    Glad they finally came around.  But i am even more happy that NxStage is working so well for you, keep up the great work my friend. 

[Zach]

Also remember to include at least one Renal Dietitian--not just a Registered Dietitian.
Our diets are a lot more complex than just handing out lists of what we can and cannot eat.

The Renalist.