A Story from Janet Bierdon, Director of Admissions, Muhlenberg Regional Medical Center

Told By: Birute Regine and Roger Lewin

• self-organization
• emergence
• good enough vision
• tune to the edge
• complexity lens
• multiple actions
• min specs
  
  

Charity care, state money given to hospitals to pay for the care of indigent patients, conjures up images of another time, of a Dickensian ethic of social responsibility—caring for the less fortunate. As it is with many government programs, magnanimous intentions become entangled in the snarl of bureaucratic requirements, and nuisance upstages altruism. The difficulty with the multi-step process of charity care, which includes follow-up, is not just that the procedure is very complicated, but that it requires information from a population who are often homeless. These people are not likely to be carrying their tax statements for the last five years in their transient bag of meager possessions.

The process of qualifying patients for charity care is so arduous and time consuming, that many hospitals don’t even bother. Swallowing the costs seems the lesser of two evils. But with the pressure of mounting economic constraints, ignoring this potential source of revenue is no longer feasible. A popular option is hiring outside consultants to sort through the mess. Although the cost of consultants can be high, the increased revenue still leaves hospitals ahead. That was exactly what senior management were considering at Muhlenberg Regional Medical Center in Plainfield, New Jersey. Until Janet Bierdron, Director of Admissions, got wind of it.

As Director of Admissions, Janet heads an autonomous department, the only one of its kind at Muhlenberg. It’s a large department of 87 employees, comprised of the registration for both admitted in-patients and out-patients, all the ER registrations and two clinical areas. Traditionally one department took care of the patient while another billed them–the two were always kept separate. Janet’s department was unique, in that it combined both the clinical and financial functions. Janet describes admissions this way. "It’s an integrated system, that’s constantly changing and growing and evolving, based on what we’re exposed to at the time. It’s organic. It’s always fluid and moving in and out of states, always adjusting." Janet’s description of Admissions colorfully encompasses the attributes of a complex adaptive system–because it is one. Part of the department’s most recent evolution has been to incorporate charity care. Since the financial department was already tied to admission, it seemed a logical step to integrate charity care as part of admission work.

When Janet heard that the hospital was considering outside consultants to run the charity care operation, it bothered her. "I couldn’t understand why they would want to bring somebody from the outside who had no loyalty to the hospital, and reward them. When you have resources here, why not use incentives for your own employees?"

Janet had a particular resource in mind–three clerks who had approached her and insisted that the hospital didn’t need outside people. They could do the job, they claimed, because they had a relationship with the people. Because it was their community. In particular, it was Rhonda Simms, who would eventually become the heart and soul of the project, that suggested a novel approach for dealing with charity care—go to the patients’ homes to get the information needed to qualify them for charity care.

Janet recognized the force of the idea—the hospital going to the community rather than waiting for the community to come to the hospital. She remembered a time noticing Rhonda talk to a male patient who couldn’t fill out a form. He couldn’t fill it out because he didn’t have his glasses with him—they were at home. Although the many reasons for not filling out the forms may seem small, for the patient, unfamiliar with the ways of bureaucracy, obstacles can become overwhelming. And the hospital, up to that point, had been unable to overcome them. Hospital administrators had tried all kinds of incentives to draw the charity care population into the hospital, like offering free turkeys or a $100 gift certificate. But none of them worked. And the reasons were very simple—eligible people didn’t come in because they didn’t feel well, because they were disorganized, because they didn’t know about the availability of funding for them. Doing home visits made perfect sense. And it had made sense to Rhonda for quite awhile, who was already doing it on her own time, usually on the way home from work.

Janet developed an incentive plan. She reasoned that having a financial incentive to visit psychiatric patients and drug addicts might give her staff that little bit of extra energy needed to try one last time, to make that last phone call. $18,000 would be divided amongst those involved, proportionate to the amount of individual effort invested. The incentive program would kick in after revenue exceeded the $7 million that was collected the previous year.

Egged on by her staff, Janet argued that her people should be allowed to engage in head-to-head competition with the outside consultants, when the time came to make a sales pitch to senior management for the job. The consultants put on a slick performance, and demonstrated that, for a half million dollars, they could have charity care benefit the hospital. Janet showed how her people could offer everything the consultancy offered. And even better—the hospital would be utilizing its own people and letting its own people benefit from the incentive. She won, and the challenge was theirs.

Janet reallocated one position, which cost nothing, and hired one extra financial counselor, bringing the staff up to five. A car was needed, to drive to patients’ homes, typically in some of the rougher sections of town. One was bought. The office needed a copying machine; a couple of hundred dollars was spent on getting copies of birth certificates. All the extra costs came, at most, to $50,000.

Rhonda and her colleagues got to work. "I’ve never experienced such a committed group that worked so hard, so professionally, so diligently," Janet recounts with a continued sense of awe. "This staff was fearless. And the reason they were fearless is because this is their community. These are their patients. They have a relationship with these people. They’ve developed a tie. And because the patients aren’t threatened, they’re willing to work with us."

Within ten months charity care revenue had increased by $2 million. From a business perspective, five people generating an income of $2 million would be regarded as highly successful entrepreneurs! So, charity care was a huge economic success. But it was more than that.

Mother Theresa of Plainfield

There are good reasons why Rhonda is known as the Mother Theresa of Plainfield, not least of which is that she herself embodies the spirit of charity care. She sincerely cares and wants to help, and she goes the distance for people. Patients recognize this in her and consequently trust her, which is no small achievement in the HIV community with which she primarily deals. They know her commitment first hand—she sticks with the patients from the beginning of their care to the end. She sees them through the process. And in that process of helping, she educates them about a system they don’t understand, and she herself learns many procedures, from Medicaid to disability to social security. And she does it because "it makes me feel good."

Rhonda, who has lived in Plainfield all her life, recounts a story.

"I had a patient in the hospital ...she refused to talk to anybody...we have a lot of those. If the nursing staff can’t get through to them, they call me. I went up, and tried to get her to open up. A lot of people just need somebody to cry with, need to tell somebody their problems. She started to cry and talk. So I just listened; I don’t do much talking. Finally she opened up. It turned out her family didn’t know that she was HIV positive. She didn’t know how she could tell them. I told her I would go with her when it was time for her to tell her family. I told her about Plainfield Health Center; that it is very involved with HIV people, that they have counselors there. I told her they can help her get her medication paid for. I told her to trust me. And she did."

It’s not surprising that Rhonda is regarded as the "last resort"—when all else fails, go to Rhonda.

But the story doesn’t end there for Rhonda. Two days later, the woman called Rhonda in a terrible state of distress and despair, barely coherent: she and her parents were threatened with eviction, was the fragmented message. Rhonda tried to calm her, and gave her what advice she could. Later, Rhonda went to the woman’s house–it was dirty, no food, no heat. They were using the gas stove to warm the place, barely. Rhonda persuaded the woman’s parents, who were elderly, to listen to the police who were at the house, who were urging them to be admitted into a nursing home. The parents listened to Rhonda, and a place was found for them. The young woman moved in with friends. Rhonda continues to be, as with many others, a vital resource for this family, as someone they turn to for information, for guidance, for hope.

But it’s not easy, given the number of people wanting help; their faith and expectation that Rhonda will rescue them, will take care of them, and given the limited options that Rhonda in fact usually has available to her. "I just do what I can," she sighs, "but sometimes it’s so bad I just don’t pick up the phone."

Unpredictable unfolding

The story of charity care is a tale of unpredictability; none of it could have been anticipated. Rhonda, whose initial intention was to go to the community in order to gather charity care information, never expected to find her work turning in a new direction. By going into the community, Rhonda had entered their world and their social problems.

Charity care became more than financial assistance—it became human assistance and a medical intervention. "When people are burdened with financial problems and they’re sick, and somebody helps them with the financial problems," notes Janet, "then they can concentrate on getting better. It makes a major difference in their lives." Rhonda adds: "I think this has an impact on how the patients see the hospital. It’s not just the hospital calling up to say that they owe so much on their bill. Now the patients know they have someone who is going to help, who will listen to them, who will take them to where they need to go. I give them money for the bus fare," Rhonda states as an aside. "And they always give it back."

Another unanticipated outgrowth of the charity care project was the impact that Rhonda’s home visits would have on the community. Her high visibility makes her a well known person in the community. They know her by sight. They recognize her car. She seeks them wherever they are: at their bars, at the strip joints, at the houses of ill repute. And the community helps her, cooperates in tracking patients down. When she is looking for someone, folks will tell her where they saw them last. "Many of these patients don’t have phones, but I just find them," says Rhonda, and then adds with a chuckle, "I always find them."

Also, no one expected the Plainfield Health Center’s collaboration with the hospital. The health center is a place that people go to for minor medical work. "What if we got the information we needed there, so if patients needed to be admitted to the hospital later, we’d already have the information?" mused Rhonda. So Janet arranged to have someone on site, and the community loved it. All the paper work could be done before patients became seriously ill, and in need of admission to the hospital. And the patients felt prepared, ready in case of an emergency.

Rhonda’s presence in the community and her involvement with HIV patients has become a conduit for creating more connections in the community, another unexpected turn. As a symbol of efficacy and a source of information, Rhonda has become a reference point for many people in the community—someone they all know. Patients in the HIV counseling group at the Health Center started talking about her. Patients were referring other people to her. And consequently, a population that tends to be characteristically isolated, were talking to each other. They were sharing information about resources. They were learning from their friends; they were educating their friends about the system. They didn’t do that before. Rhonda has inadvertently forged a connection for the community to itself. "We talk about the financial incentive," reflects Janet, "but that’s not what drives this. What drives these five women is the commitment to the community, to each other, and to the patients." And that commitment has left an indelible mark in the community.

Principles
Complexity lens
Good enough vision

Alignment

When Janet talks about the charity care project, she describes herself as having very little input and sees Rhonda and her colleagues as running themselves, or in complexity terms, they are self-organizing. She attributes this to alignment: "Alignment happens when you take your people and the structure and the technology and the culture and you align it with each other and within your environment." When people see, feel, and become a part of this web of connection, when they are joined by a common understanding of purpose, and when the commitment is steadfast and true, alignment emerges out of this constellation of rich connection. "When alignment works, observes Janet, "you know that you’ve got it. Like this group, you can feel the energy."

Alignment allows for greater flexibility and adaptability in a system. In dance, alignment is central to a dancer’s movement. When the body, and particularly the vertebrae, all stack up properly, the dancer has a greater range of motion, and that motion is more efficient and is accomplished with greater ease. A triple turn is not such an enormous feat when a dancer is aligned. And it looks easy–until you try it yourself. Similarly, alignment in a complex system lends itself to an ease and efficiency with the tasks at hand. Janet half-teases when she gives two goals to keep her people aligned: "make me look good, and make me money!"

Let’s pretend that Janet had a specific idea about how she wanted the charity care project to work. She would then develop a plan, a collection of actions that she hopes will take her from A, where she is now, to Z, which is where she wants to be. But the process is much more like alphabet soup than a linear series of letters. Janet allows things to unfold. And this unfolding towards order and alignment transpires within the constant buzz of many diverse connections occurring simultaneously, unexpectedly, unpredictably. Possibilities of connection are endless and lots of connections make for a robust system. Lots of connections allows for a continual state of adjustment, for an iteration of ideas. And lots of connections are the source of self-organization that allows something new and unexpected to emerge. What, then, are the connections that were pivotal in this success story, where $8-an-hour clerks generate $2 million in ten months?

Connecting by listening

If the charity care story could be reduced to one important point, it would be the power of listening as a means of connecting. It began with Janet listening to Rhonda. "When Janet became responsible for this area, she started talking to me, listening to me. That’s the key—listen to your people," says Rhonda emphatically. "I had no title or anything. I was just a regular worker like everybody else. Janet just sat down and listened to what I had to say. She was like an angel who came to me...she just listened. A lot of employees like to be heard, but nobody listens. I’ve been here ten years and everybody knows me now, but they didn’t before. Janet makes you want to do better in your job."

Similarly, we have heard that Rhonda makes the same connection with her patients. She listens to the homeless, to the sick, in a way that they, too, have not been listened to.

Principles
Multiple actions

Connecting through action

It was not just the fact that Janet listened; it was also that she acted—immediately. Immediacy of response commands more connections, creates a momentum. As Rhonda says, "When I told Janet an idea I had, she said, ‘great idea’ and she moved right on it. It’s not like when you tell somebody something, and then you never hear about it again. With Janet, the next day it is done."

Janet sees her role as mobilizing others into action. "These women were working in places where they weren’t recognized as having value," she says. "Now they are recognized as having value and are given the space to do what they need to do." Janet both acts on their behalf and also allows them to act.

Connecting to resources

The charity care story is a dynamic weave of putting people in touch with external resources, and their own internal resources. Janet provides the external resources the group needs to accomplish their work, like providing a car. Similarly, Rhonda connects her patients to resources that can provide them with medical assistance.

But the more powerful connection is internally—connecting to oneself as a resource. Janet encourages this connection through her conviction that "the people who do the work should have the greatest say in how it should be done." And this has manifested with the five women as a profound appreciation of the diverse skills they bring to the project–Nancy’s math skills, Doretta’s medical knowledge, Lisa’s Medicaid expertise, Melissa’s insights–and Rhonda’s skills at connecting with people in the most difficult of social circumstances. Tapping into internal resources they didn’t know they had, collectively these five women become fearless. And anything is possible.

Connecting to trust

Underlying all the connections is a developing connection to trust—trusting the process, trusting yourself, trusting your co-workers. Trust is the lubricant that eases all tasks. As Janet puts it: "I can’t over-emphasize my feelings on trust. I trust my staff completely. I give them the benefit of the doubt. I trust in their ability. I trust that if they can’t do something they’ll tell me. I trust that they are in there with me. And that we’re going to march in a battle or a challenge and that we can rely on each other no matter what. I trust that they’ll tell me if I’m going down the wrong road. I trust that I can talk to them."

Janet wins their trust by talking straight: "I tell them right up front if you’re going to work in this area and for me, this is the way we do things. If you have an idea, if you want to make a decision or you want to take action, do it. Don’t come to me for every little thing, because there’s no way I could manage this department, virtually unassisted as I do, unless I could trust the people who are going to take things into their own hands. They have to feel comfortable that they can make decisions. So this is the kind of person I’m looking for. Not everyone can work in this kind of environment."

Connecting to community

Only when the staff at Muhlenberg entered the context and reality of the patients—that is, reached into the community—was the hospital able to serve the people it sought to help. The healing process is no longer limited to the walls of the hospital but rather is accessible through the clarity and the strength of the connection to the community.

The cascades

The cascade of empowerment and creativity unleashed by the simple act of listening–Janet listening to Rhonda, Rhonda listening to patients, patients listening to each other–is part of a larger cascade at Muhlenberg. For, just as Rhonda feels liberated to achieve far beyond what was expected of her when Janet took time to listen, Janet feels similarly liberated when her boss, Mary Anne Keyes, VP for nursing, took time to listen to her.

This rich cascade of connections, replicating themselves, like dynamic fractals, circling themselves like whirling dirvishes, both within the hospital and outside into the community, in turn kindles a stellar opportunity—a time for all to heal.

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