You should also know that I’m fundamentally lazy or, maybe more charitably, pathologically practical. I really have an aversion to wasting time on tasks better done by others or not at all (like making the bed) or by computers.
Actually, my entry into the clinical world coincided with the advent of the minicomputer in the late ’70s. It didn’t take me long to figure out that my Radio Shack TRS-80 could save me all kinds of time. For example, I had no patience for tallying the scores and ratios that were involved in using the Rorschach inkblot test – and so I wrote a program that did it for me. Of course, it did the calculations a whole lot more accurately and reliably than I ever could.
So I’ve been into analytics, and workflows, and data-driven management before all those things were cool. Actually, it’s been fun to see how much those concepts have taken hold all these years later.
My experience shows how data gathering can be effective, perhaps in ways that might not be terribly obvious. If you manage a behavioral health agency, your top goal is to assemble and retain a competent and productive crew of clinicians. Without solid and loyal providers, nothing works well or for long. Forget quality of care. Forget generating sufficient revenue. Forget building a presence in your community. All of that comes down to the quality of providers you can attract and keep. To quote my grandmother, who ran a dry cleaning shop in Amherst, Massachusetts, “Michael, remember, it all comes down to getting good help and holding on to them. If you own a business, you work for the help.”
We all know how hard it is to find good people and keep them over the long haul. The supply of clinicians is low, the demands for their services is high, and the job is hard and often frustrating. If you take someone for granted, even briefly, they’ll be out the door before you know it, leaving you with a caseload to cover and another search to conduct.
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The turnover rate in the mental health world is indeed a major problem for agencies. Most are understaffed to begin with, so there’s not a whole lot of cushion if someone departs. Turnover is especially problematic in our field because we serve a patient population that expects (and usually requires) a provider who knows them and is committed to their care over time. If your cardiologist leaves, it’s usually not a big deal for someone to take over your case, read the last few notes, and manage your care. That’s not the case in behavioral health. Much more of the treatment is about the relationship and, most importantly, the trust the provider and patient build slowly over years.
Much has been written about how to retain staff in behavioral health agencies. Suggestions from some experts are pretty obvious – staff tend to stay at jobs where the pay is good and the benefits ample (especially when it comes to vacation time and policies for taking “mental health” days). Of course, many managers don’t have control over salaries and personnel policies. We can advocate for our clinicians and look for ways to augment their income, but often we don’t have a lot to offer them.
Where we administrators can make a difference for our staff is in managing the quality of their work life. We can strive to limit staff burnout, fatigue, and exhaustion. Clinicians who feel overwhelmed by their caseloads are clinicians who are likely to be less effective in treating their clients. They’ll also be less loyal to the organization, less likely to collaborate with others on patient care, and be at greater risk for health and mental health problems of their own. Unless we keep an eye on how our clinicians are functioning and respond effectively when we detect vulnerabilities, we can find ourselves receiving a letter that starts, “Dear Dr. Gordon: I am writing to indicate that I will be terminating my employment in two weeks.”
How can we gauge how our staff are doing? Well, of course, we can (and should) ask them on a regular basis. Our staff should know that we’re focused on keeping them productive and reasonably content. That alone can help the cause. So can providing regular opportunities to let staff tell you what’s on their mind, positive or negative. For a lot of us, just having a chance to vent can be beneficial.
Sadly, my experience is that mental health professionals, while well-versed in how to get patients to communicate their issues are, as a group, pretty awful at communicating their own concerns or coming up with suggestions for improvements. Probably like most of you, I find it hard to get these highly educated and caring professionals to go beyond voicing general dissatisfaction. Getting them to offer specific ideas for how to improve clinic life is almost impossible.
However, I have found that I can get an inkling of where things stand with one of my staff by sidling up to my computer monitor, logging into our EHR, and generating a few reports.
For me, the best place to start is with a report that shows the number of missed appointments by patients and by staff. Specifically, I can see how often patients fail to show up for a session (either without calling or calling at the last minute to cancel). I can also see how often clinicians miss scheduled appointments. My experience is that these no-show reports provide a window into how both professionals and patients are faring.
On the patient side, a high no-show rate is a sure sign that all is not well with the case. Patients who are well-engaged and progressing in therapy tend to come to appointments faithfully. I hope that’s one of the reasons they’re doing well. Those who miss more appointments than they make have something getting in the way of their engagement. It could be a sign that they need a higher level of care, that they don’t feel their therapist is a good fit, or any number of other factors – many of which relate to the patient-therapist connection or lack thereof.
Regardless of the reason, devoted clinicians know they can’t treat an empty chair and feel frustrated when the appointment time comes and goes. Some clinicians, though, are happy when patients don’t show because that means they’ll have time to work on notes or they won’t have to deal with what may be a difficult case.
It’s also not a good sign when clinicians have to cancel appointments. If it’s for health reasons, that might indicate that the stress of the job is having untoward health effects. I have been involved in situations where the clinician’s cancelations reflect their discomfort meeting with a certain patient or family. To me, these no-show reports are supervisory gold.
Next, I would generate a report that shows each clinician’s caseload and the number of kept appointments over a date range. Too high or too low can mean something might be going on with the clinician. I’ve had staff who, for whatever reason, overload themselves unmercifully with cases and start to show signs of burnout. Of course, some clinicians don’t see enough cases. That can mean all kinds of things, but sometimes it relates to their stress levels. Either way, the numbers this report generate can lead to important discussions.
Now comes the case acuity report. That’s based on a number from 1 to 5 we settle on for a case after intake. It’s somewhat subjective, but is generally derived by looking at the seriousness of the diagnosis or diagnoses, the person’s treatment history, and, in the case of child cases, whether mom has a history of depression (that comes from research we’ve conducted that looks at predictors of no-shows).
It never hurts to get a general sense of how many challenging cases a clinician has at any moment. You know how it is – one difficult case can wreak havoc on a clinician’s joie de vivre. Keeping an eye on the nature of a clinician’s caseload offers an excellent opportunity to review the challenging case and, if nothing else, lets the clinician know that you understand why they might feel frustrated.
A final report to consider is the paperwork status listing. It shows the extent to which a staff member is current with required documentation. I press a button and I can tell which of my staff are way behind in their paperwork. The listing doesn’t tell me why they’re behind or what to do about it, but it does tell me something’s up – perhaps they’re too busy or too tired or too something. Maybe they were writing notes and reports that were too long and detailed. Maybe the EHR and practice management system we were developing was complicating a workflow or falling short in the tasks it could handle. Outstanding paperwork is, in itself, stressful, and needs to be addressed. This report helps staff figure out how to catch up and make the workflow more manageable. You might have a conversation about scheduling a day or so to catch up on paperwork or instruct them on how the software could make it easier for them.
Running a behavioral health clinic is fraught with challenges and stressors. You can’t improve your clinicians’ work life if you don’t know what’s going on. Your EHR should provide the facts and figures that point to potential problems so you can address them. The moral of the story: fly by the seat of your data, not by the seat of your pants.