The Virtual Administrator

That may change, if IT innovations emerging recently start making their mark. For the first time, it looks as though long-term care managers are going to be able to track their facilities’ performance in real time and to whatever depth of detail they care to go-in other words, be able to do their jobs as “virtual administrators” backed up by more information than they’ve ever had before. Today’s administrators can be at the bedside with a CNA, eavesdrop on an MDS coordinator, see how well Mrs. Jones in Room 13 is doing with her new diet, and evaluate the facility’s performance against the competitor’s down the street-all with the push of a few buttons.

Three vendors have agreed to share their perspectives with our readers on some of the IT tools available to the virtual administrator. Their articles follow.

The Minimum Data Set (MDS) has become the richest database in healthcare. Summary data from the MDS are being reviewed by a variety of groups and agencies that have an interest in monitoring the performance levels of individual facilities, as well as the industry as a whole. Unfortunately, most facilities don’t have the capability of using MDS data internally to improve quality and explain their processes. However, with the appropriately structured approach, MDS data can now be used by administrators to improve care and upgrade operations on a continuous basis.

The process must start with the MDS data being screened for internal logic, because inaccurate or slipshod recording from one shift to the next doesn’t do anyone any good. Once screened, the data can be drilled down in a number of ways. A resident who benefits from progressive long-term rehabilitation might have as many as 15 assessments during a 10-month period (any facility tracking only quarterly assessments is probably losing money). Following resident data over time is vital to show: (1) how the facility is performing on its Quality Measures and Quality Indicators; (2) how individual residents are progressing, or not progressing, in specific areas of their care (e.g., nutrition, pressure sore healing, pain management, restraints, rehab)-and the possible reasons why; and (3) how the facility compares in QM/QI performance with other facilities in the state and nation.

This information technology also allows the facility to progress from quality assurance to quality improvement through the creation of what are called statistical process control charts (SPCCs), which aggregate data and show patterns of change over time. Using this approach, administrators can track facility performance, resident status, and federal quality-initiative compliance as frequently as they find useful. They can step in, in real time, to initiate corrective action, if necessary.

The administrator won’t be pleased by everything he or she sees. But the fact that the administrator is looking for areas needing improvement and is doing something about them when found counts for a lot.

Popping the hood of an automobile reveals an astonishing engineering feat that makes one ponder how in the world they’re able to make all the wheels, pulleys, switches, cylinders, hoses, belts, tubes, and gaskets work together and function the instant the key is turned. No less a marvel is the massive complexity the long-term care executive faces in today’s world as he or she focuses on care, cash, and compliance issues. There are a lot of parts and pieces that could “break down” at any moment.

Long-term care has for years been charged with creating paper-driven (or, in some cases, electronically driven) care plans in an attempt to categorically present an accurate picture of a resident’s daily state of need, quality of life, and wellness. Likewise, finance departments generating month-end, or “30-day look back,” reports exhaust countless hours.

While both clinical and financial information systems reportedly serve the purposes intended and are currently the most common systems used, neither traditional care-documentation approaches nor month-end financials can authenticate the actual care rendered, nor the true cost of the resources consumed. In short, neither approach communicates what is truly occurring “under the hood” (e.g., at the bedside or in the therapy room, dining room, or hallway, for that matter). Both commonly fall short in today’s fast-paced decision-making environment, which requires accurate, up-to-date data based on real-time, business-based intelligence reporting.

Current CNA “smock pocket” resident information filing systems, created at shift report, fall drastically short in critical resident information. In most facilities, staff are required to recall, in detail, all the services they rendered, all measurements and observations made, and evaluations noted for all their resident assignments during an eight-hour period. In many cases, however, staff will undoubtedly go home knowing that the information or data they recorded was incomplete and/or imprecise. Most are aware that this information does not represent their full day’s workload and the services they actually accomplished, or resident changes they might have observed. In many cases, when documentation inconsistencies are discovered during a survey, attempts at remedies often result in yet another paper form being thrown at the CNAs for tracking their daily activities. This cycle continues, with the CNAs filling out more forms that management then has to “audit,” thus perpetuating an already inefficient system.

Given all this complexity, however, the most crucial role of any manager is to recognize that conditions must be measurable in some form or another. Put simply: If it cannot be measured, it cannot be managed. To obtain and maintain successful measurement, managers must go to where the action is-they must “pop the hood” to see whether the various operational metrics, or standards of measure, fit together; if and when they depend upon each other; and if there are trends of care or dynamics that are predictable. Managers must determine what is working and what is not, addressing such questions as:

Where are potential breakdowns in service? Are staffing schedules balanced, or are uneven workloads causing burnout and staff turnover? What skill mix and staff allocations work best, and at what time of day? Are plans of care implemented evenly throughout the day, or are there bottlenecks and conflicts between activities, i.e., therapy and dietary department schedules? Are resident plans of care up to date and actually followed? Can the care be authenticated? How are changes in care plans or, conversely, changes in resident needs, articulated to appropriate staff in a timely manner? From a financial standpoint, which residents are consuming the most resources, which ones the least, and why?

Although this type of information is highly significant to the manager, it is critical that such analytics and resultant information also be made available to the entire staff in a timely way, to help them sustain their full potential and caring capacity. This can only be accomplished by getting the right information to the right person at the right time, and in a format they recognize and can easily use.

To accomplish this, the modern LTC business intelligence and information management system must:

1. Eliminate as much redundant, time-consuming paperwork as possible.
2. Keep the data recording quick, intuitive, simple, and “friendly” for the staff to learn and use consistently.
3. Begin the business intelligence process at the bedside and roll the in-formatics up to the executive suite (as opposed to “top-down”).
4. Have record keeping done naturally by the staff, i.e., without forcing them to change the way they care for residents.
5. Rely on an architecture that allows LTC managers to decide on the scope, scale, and pace of implementation, based on the cultural and financial realities of their organizations.
6. Record at the bedside what was done and for whom, with a date and time stamp affixed to every entry made.
7. Be “device-agnostic,” in that it can be implemented on PDAs, tablets, laptops, cell/smart phones, and/or desktops, based on client-specific requirements.
8. Use a real-time, wireless platform on which data can be recorded, stored, and retrieved on demand whenever and wherever any authorized staff member, in accordance with HIPAA requirements, has access to the Internet or internal network.
9. Transfer data immediately to centralized storage facilities, rather than storing them on devices, to ensure that critical data are not lost if the device is broken or removed from the facility.
10. Recognize that the true nursing “point of care” can be anywhere in a facility, and record-keeping capability should be likewise.
11. Be adaptable to change processes by any management team member at any time as required, within its configurable architecture, allowing leaders to react immediately to new informational demands rather than requiring them to wait for months and sometimes years for new software versions.
12. Allow for tracking of any service or resident condition at any time, as needed.
13. Allow for instantaneous, real-time resident profile updates, available on a handheld device, so all bedside staff are immediately aware of any resident care plan updates and changes.
14. Retrieve any policy, protocol, or procedure on a handheld device when needed.
15. Have the potential to recall at any time in-service lessons or treatment approaches, as needed.
16. Have the capacity to construct real-time financial modeling that validates and allocates the true cost of care per resident, staff resource allocations, and supply usage on any shift, day, week, or month.
17. Easily interface with all existing clinical and financial software applications.

Tim O’Connor, Senior Vice-President, has had more than 31 years of healthcare experience, the most recent 15 years of which he has served as president and CEO of a 450-resident CCRC. O’Connor Informatics Group’s Accountable Resident Care solutions apply wireless communication capabilities to enable LTC executives to measure the quality, efficiency, and efficacy of care; validate the accuracy of the MDS and CMI; and monitor and measure resource utilization. For further information, phone Tim O’Connor at (607) 857-6000 or e-mail toconnor@oconnorig.com. To comment on this article, please send e-mail to oconnor0104@nursinghomesmagazine.com.

Software development companies in all industries are developing methods of providing their products in a hosted environment. Instead of managing their own software “on premises,” long-term care providers can have applications installed and maintained on an off-site computer, with software accessed and used via an Internet connection. All administration of the software and its related hardware and data management are conducted by experienced computer professionals on a subscription basis.

Traditional ASPs
Traditional application service providers (ASPs) provide tangible advantages over packaged-software-based models, especially in allowing staff to focus on care delivery; however, some fail to take advantage of the incredible potential offered by existing and emerging Web-based technologies and their potential economies of scale. The downsides for end users are:

1. These products are Web-enabled, not Web-based. Specialized third-party products and complex configurations are needed to make client/server software (the model most nursing homes are familiar with) Internet-enabled. Making Web-enabled software “fit” so that it operates properly requires additional resources (for example, extra bandwidth to perform at acceptable levels, which in itself often eclipses any cost savings). There are also risks to reliability, security, and overall performance.

2. Many initial ASPs failed to embrace the power of multitenant hosting (i.e., all customers hosted on the same servers). These ASPs favored single-tenant hosting, meaning that a server had to be managed for each customer. This turns out to be a costly exercise that also has dramatic implications for customer service and vendor response times.

IBSPs close the gap on Web-enabled ASPs in two ways. First, they are built on technology that was designed from the ground up to be delivered over the Web as a service to thousands of customers. Second, IBSPs embrace multitenant hosting, in which a single group of powerful servers delivers the application to all customers, creating enormous economies of scale and lowering costs dramatically.

Most importantly, because revenues are tied directly to subscriptions, IBSPs are oriented to focus on customer needs and product development. This model gives priority to maximizing customer retention rather than to sales and marketing of ever-changing software products.

An IBSP, because it is built from the ground up as a Web site, works like a well-designed Web site should and is designed for the end user, not for the highly skilled computer technician. Start-up is immediate, and staff training takes minutes, not weeks. Because the Web interface was created for mass use, navigation has been simplified to single-click, familiar hyperlinks, and forward and back buttons. IBSP upgrades happen seam-lessly and automatically.

An IBSP can immediately address software problems as they are recognized; therefore, the product itself is refined quicker and adapted to the needs of the user, as opposed to traditional-model providers that wait until they can package multiple repairs in one update, thus extending the time between problem recognition and repair.

Realizing that security breaches and privacy compromises will directly affect customer retention (especially in the era of HIPAA), IBSPs use the highest level of security protocols to protect data. Off-site, monitored disks and information are backed up nightly. Production equipment is located at a data-processing center maintaining 24-hour security. Intrusion-detection systems, firewalls, and other application security safeguards provide the highest level of protection. IBSPs also typically use SSL 128-bit encryption to protect all transactions.

IBSPs are delivered as a service. There is no up-front investment, long-term contract, or implementation required. Because of the economies of scale afforded by multitenant hosting, IBSPs can provide 99.9% application availability in their service-level agreements.

The table shows key comparisons between packaged software, traditional ASPs, and IBSPs. An analogy also might be made to obtaining power from a power plant:

• Using packaged software in an on-premise client/server model-the traditional model-is like building your own power plant.
• Using the Web-enabled ASP is like having someone build the power plant and manage it for you.
• Using an IBSP is like having the power company deliver power to you.

IBSPs may not be for everyone, but their value cannot be ignored. When making the next software decision, take a close look at this emerging IT model. It’s definitely “Web-simple.” NH