Idiopathic delayed note syndrome
September 12, 2012 11:58 AM   Subscribe

I supervise a person who has enormous difficulty finishing her case notes. My efforts to remediate her so far have been unsuccessful. How can I help her finish her work?

I am the supervisor for a clinical worker. Like most clinicians, each visit with a patient is documented in a note in the record, which has to be signed to complete it. We switched over to an electronic medical record with computerized notes a few months ago, and after an initial period of difficulty and grumbling, almost everyone in the group achieved a rhythm where they finished their notes after their patient session or at most a few days afterwards. However, this person seems to be incapable of actually signing her notes, leaving them to accumulate in her inbox.

She is very nice, but generally kind of anxious and inefficient person who is bad at multitasking. She has been here for a very long time, and is generally beloved by her patients--spending lots of time talking with them in person and on the phone. Her patient sessions usually run over time by at least 1 hour. However, she is very good at the clinical aspects of her work, just not the record keeping. This person has always had difficulty finishing her notes, but when we had paper charts the sheer accumulation would usually get her to finish them up in a few days. Now there is no physical presence clogging up her desk.

The problem is that those notes MUST BE FINISHED. There are legal, regulatory and billing issues around having things unsigned for long periods, and she's way out of any reasonable grace period on most of these. My institution does not have a formal policy on this though--apparently they are in the process of writing one, but it's slow going. So far higher-level intervention in the case has taken the form of my superiors asking me to get her to finish stuff.

I've looked at the notes, and they're very detailed and pretty complete. Most of them just need a couple of concluding sentences and an electronic signature. I have looked at them with her, and if these were my notes it would take no longer than 5 minutes to complete each one. It is apparently taking her an average of about 25 minutes to complete a single note (which are already 90% done), which, no wonder she's falling behind (to the tune of 500+ unsigned notes at the moment).

I let things go on too long before getting really hardnosed about it, because she had some very significant stressors in her personal life earlier this year, and I honestly did think she would get caught up. I think there is a very substantial component of shame and perfectonism going on, and possibly also some actual compulsiveness, but I'm not sure how to help her.
I've talked to her about it on multiple, multiple occasions and she always says the same thing, which is that she was behind for X reason but is starting to get caught up now and she just needs to take some time on the weekends, etc. Meanwhile she continues to fall behind. Here's what I've done at this point:

-she has agreed to complete 50 notes per week. So far this is a big failure; she's still falling further behind.

- we are meeting on a weekly basis for a progress check. Again, so far this is unsuccessful.

-I've found time to give her the equivalent of a week just to complete some of her backlog of notes. (These days are mostly upcoming--the scheduling required some time to set up). But this is obviously not a long-term solution.

-She already works less than full time.

-She understands why she needs to have these done and that she is risking both her job and the practice's accreditation

-I and another manager have met with her to make sure she is comfortable with the EMR system. She hasn't learned a lot of the expert tips/tricks, but she is comfortable with all the basics.

-I've tried to give her help on structuring her time, focusing on essentials, setting external limits on how long she works on a single document (I suggested using a timer).

-I have considered completing some of these for her, and just have her look them over and sign off on them, but I have a lot of my own work to do and can't really do it in the numbers she needs.

I do not have the power to fire this person directly, although probably I could make it happen if I showed that she had failed remediation efforts, but I would really rather not. She is well-liked, a good clinician, and has had a very rough year. But the number of unsigned notes stretching back months is approaching the ludicrous and attracting unwelcome attention from higher administration.

What else can I do to help her 1) finish her astounding backlog of unfinished work, and 2) stay on top of new notes? I'm running out of managerial tricks.
posted by The Elusive Architeuthis to Work & Money (39 answers total) 9 users marked this as a favorite
Her patient sessions run over an hour longer than they're supposed to?! That seems to be the answer to her time problem right there. Tell her that she's not modeling appropriate boundary-setting behavior for her patients by letting sessions run so much longer than scheduled and have her work on ending her sessions on time. Once she has the free time, she can begin working on her insane backlog.
posted by pineappleheart at 12:07 PM on September 12, 2012 [8 favorites]

Oh geez, this is a hard one, there's always one luddite, one person who is a special snowflake who needs to be exempt from working the computer.

Until she gets the backlog done, she's going to need to set aside a specific amount of time daily to catch it up and complete it. She may need to do this every day for the rest of her working life.

Since she's clearly a poor time manager, this will need to be first thing in the morning. No clients, no other stuff until 2 hours after she usually arrives. Those two hours MUST be devoted to clearing up the back log.

Also, you'll need to document this, for her review, and as a disciplinary issue.

It doesn't matter that she is well-liked, a good clinician or that she's had a rough year, this HAS to happen.

She must commit to clearing the backlog and SHE needs to be in the office and devote 10 hours a week to taking care of it. If she refuses, she'll need to be fired.

Being a supervisor without power is a terrible position to be in, but you can't carry her any more.

"Gloria, the paperwork backlog is unacceptable. I need you to be in here 8:30 to 10:30, every working day until you are caught up. If this is something you aren't willing to do, I'm afraid I'll have to refer it to (higher up who can fire her) for resolution. I need you to sign this document that says that we discussed this issue, that you are aware that it is a critical issue and that you are prepared to take care of it before the end of the month."

Then provider her with an expectation of how many items need to be updated and cleared at the end of every week.

This can't be allowed to continue.
posted by Ruthless Bunny at 12:08 PM on September 12, 2012 [12 favorites]

Allow for the possibility that she herself has a health condition that is creating obstacles. The inability to close a file / task is a pretty classic workplace manifestation of OCD, related to perfectionism.
posted by charmcityblues at 12:12 PM on September 12, 2012 [7 favorites]

I used to have a job that required something like this; tasks were generally easy but very individualized, and files piled up very quickly if I didn't stay on top of it.

What worked well for me was to have an hour every morning, before other things were scheduled, to devote to these files, and to stick to daily goals (instead of weekly goals).

Is that feasible in your case? Does she have time for office work before clinic gets going? Is that something you could schedule? Give her an hour, or whatever, at the start of her shift and email her ten files to do TODAY. A weekly quota isn't rigid enough; this person needs a daily workload. Do you have access to her queue? Can you check her progress daily?
posted by thirteenkiller at 12:14 PM on September 12, 2012

You need to be much more piecemeal - daily rather than weekly updates. 5 rather than 50 completed etc. Can you schedule a day for her to do nothing but catch up on say 25 notes? Once she's into the rhythm she'll probably get though more than that.

Otherwise the only thing you can do is literally sit her down with you for an hour and work through a pile of them together. Find out exactly where her snag is - get her to talk you through the process of completing a note as she's doing it. You need her to recognise what 'done' looks like. Maybe she's afraid of missing something now the format has changed - but isn't conscious of it. Work out togetherwhat the final stumble is and address it in the moment.
posted by freya_lamb at 12:14 PM on September 12, 2012 [12 favorites]

Sounds like she's a valuable asset other than this issue. Your suggestion that she's a perfectionist sounds right: Maybe she cares about the work SO MUCH that these notes can't contain all she wants to say. Perhaps she's stressing over not doing them correctly/adequately in her own eyes.

1. Remind her not to let perfect be the enemy of good.
2. Show her examples of acceptable notes.
3. Tell her that less time on these notes means more time doing what she loves: patient contact.

I'm a terrible perfectionist and was the queen of extended deadlines in college. Eventually, I was able to stop procrastinating, but it took work and practice and the ability to let go.
posted by mochapickle at 12:16 PM on September 12, 2012 [6 favorites]

Do you have to have some kind of professional registration that has standards on this? I could probably lose my licence to practice if I was regularly completing notes more than 24 hours after the appointment. My professional guidelines require my notes to be concise, relevant, accurate and contemporaneous.

I think clinicians can sometimes concentrate on the client-facing work and dismiss all the admin and paperwork as less important, but we all need to realise that things like record keeping and time management are as much about good practice as our more direct care. We're not helping our clients much if our records aren't full and where they need to be when someone needs them, or if they somehow get brought up in court and the court is able to question them because they weren't written at the time. Likewise, running an hour over might be great for the client in question (or it might not) but someone is losing that hour and it's either another client or her.

Anyway, I wonder if another way of trying to get it to sink in is to emphasise that this is all part of professional practice?

You could also look with her at her time management to build time for writing notes into her day for the clients she is seeing now so that at least she isn't adding to the backlog. If it's taking her longer than normal because she's a slow typist or because the computer interface makes her uneasy then that time needs to be built into the day. This only works if these notes are all finished properly!
posted by kadia_a at 12:22 PM on September 12, 2012 [1 favorite]

Oh, that sounds painful. Maybe schedule a Saturday where she will come in and do nothing but case notes and you will do some paperwork stuff and supervise her and work with her on them to make sure she's making progress? And you will both do this every weekend until she's caught up? (Assuming this works you could probably segue into reading a book and just keeping occasional tabs on her on subsequent Saturdays.) It would suck for both of you but it would also make it absolutely unavoidable for her to do the work. It would allow you to work with her to help her find efficient strategies for writing the notes. She also sounds pretty empathetic and the guilt about making you come to work on a weekend might be a good motivator for her. And it would get the task out of the way a bunch of notes at a time (hopefully!) by tackling the issue head on rather than being a source of anxiety where you're always asking and she's always behind.

Another idea, if paper notes being on her desk helped motivate her to do them, can you print paper tickets representing the notes from the electronic tracking system and leave them on her physical inbox?
posted by phoenixy at 12:34 PM on September 12, 2012 [3 favorites]

Just to warn you the practice one of my friends works at had this exact problem and it was causing hell with billing, admin etc. The persons ultimate solution was to take another job and just walk away from all the unfinished charts. This caused utter mayhem, as you can imagine, and several weekends worth of canceled plans for my friend and her colleagues as they scrambled to sort it out. (this is how I know, friend is not in the habit of discussing work but was explaining why she had to cancel plans)
posted by fshgrl at 12:34 PM on September 12, 2012 [1 favorite]

Is there an admin or some other kind of assistant who could work with her on this and keep her on task? Basically like what freya_lamb is suggesting but not necessarily *you*, just someone. At least until she gets through the backlog.
posted by mskyle at 12:36 PM on September 12, 2012 [5 favorites]

The Elusive Architeuthis: "-she has agreed to complete 50 notes per week. So far this is a big failure; she's still falling further behind."

Is she doing any at all in the course of a week, or is she just not doing enough to make a dent? If she's not doing any at all, then I have no useful advice to add. But if she's just not showing any significant progress, make sure she's tackling her notes in this order: Do the current notes FIRST (by whatever definition of current makes sense: all from yesterday? this morning? this week?), THEN do [some number that makes sense] of the oldest notes.

By doing the most recent ones first, and then some of the oldest, at least she isn't getting further behind while she tries to catch up. If she always tries to complete the oldest ones first, she's always going to be behind on ALL her notes.

Another idea - can you hire a temp to help her out until she's back to current? What about an intern from a local college who needs some course credit?
posted by SuperSquirrel at 12:36 PM on September 12, 2012 [2 favorites]

This is not just a matter of time management. This person has some kind of serious psychological resistance to completing the notes. You may not be able to solve this yourself.

Perhaps she wants out of the job at some level and is sabotaging herself.
posted by shivohum at 12:37 PM on September 12, 2012 [1 favorite]

I also found "Her patient sessions usually run over time by at least 1 hour" incredibly shocking. It screams of boundarylessness, at least.

But, speaking of lack of boundaries... I'm afraid someone's going to have to stand over her for 30 minutes a day, every day. As if she were a cat with an eating disorder. She is not willing and therefore not able to complete this kind of work. (I hear her! I'm the same personality type. I'm valuable and often beloved and wacky and a bit disorganized and I can let important things be undone for months. Why do you think I'm here?) But as a member of that personality type, I can assure you that I will absolutely not do any of that work until I have to, as in, someone will kill all my houseplants or burn my clothes.
posted by RJ Reynolds at 12:40 PM on September 12, 2012 [3 favorites]

It sounds like she is putting her job and your entire institution in legal and professional jeopardy by not having these done (Five HUNDRED unfinished case notes??). I understand why you are reluctant to pursue firing her, and it sounds like she's a good asset in many ways, but this situation sounds like it is in emergency territory! On the other hand, you don't want a situation like the one fshgrl describes above where the person just walks away and someone else has to complete the case notes (NOT ideal for so many reasons).

With issues like this, it's important to give the person 1) a heads-up that this is a problem 2) suggestions for a solution 3) practical support in solving the problem. It sounds like you've already done all this.

In order to take care of the #1 priority (finishing the 500 case notes), I think you need to help her by temporarily suspending her patient sessions until her backlog is attended to. As in, starting NOW her patients can't book any more appointments with her, and rather than meeting with patients, she has to spend the time finishing and signing her old case notes. I would also (if possible) reschedule any pending appointments she currently has or assign them to another clinician until her case notes are done. This way she is not caught in an endless loop where she is trying to finish old case notes while constantly adding new ones to her pile.

Then, when she's all caught up, I'd tell her that from now on, one specific block of time during her week is strictly booked off for completion of paperwork. Non-negotiable. That way, this backlog will never happen again. Communicate this to the person who takes the patient bookings so that this caseworker never, ever sees patients during this regularly scheduled block of time.

I agree that it sounds like there's some serious perfectionism going on here. (And yes, the running overtime by AN HOUR needs to stop, too!) And if it turns out there's a disability that needs to be accommodated, you can deal with that when it comes up. But for now, you can be firm and compassionate at the same time, I think. Good luck!
posted by hurdy gurdy girl at 12:46 PM on September 12, 2012 [8 favorites]

Is it possible that most or many of the notes that need to be completed could be done with slight variations on a template that you give her? If the files just need a "In conclusion, patient's complaint of [x] was treated with [a] [b] [c] and resolved in [y] time; patient is scheduled for followup in [blah]", she might be able to get past her own perfectionist tendencies (or whatever) if all she has to do for most of them is fill in the blanks.

I used to have a terrible time *starting* papers when I was in college - that first sentence! Oh my god! Until I tricked myself into "starting" in the "middle" of the paper and then rearranging as necessary; a friend had the opposite problem - she had a hell of a time writing that last paragraph. Her trick was to write the "conclusion" first, and then rearrange/rewrite when the draft was done. For some reason, rewriting something wasn't a problem for either of us, but starting that thing was.
posted by rtha at 12:46 PM on September 12, 2012 [5 favorites]

I don't have this specific problem but I certainly review a lot of backlogs of various kinds. Things I've found useful:
- triage. In this case I'd say Supersquirrels point is the key one. If she can stay on top of current notes + (small number of old notes) then you will eventually win. If she can't stay on top of the current notes then I'd say it's time to escalate. Review the old notes en bloc though - are there some that can be done quickly? If so do all the easy ones as this may then bring the total down to something much more manageable.
- model "done". Basically what Freya_Lamb said. Set an hour and go through some with her. What things are actually making the difference between what you think is a five minute clear up and her taking 25 minutes to do it.
posted by crocomancer at 12:53 PM on September 12, 2012 [1 favorite]

Is it accepted (legal, even?) to have someone help finish the digital paperwork? If it needs to get done, it needs to get done, does it matter if you have her "buy-in" on the importance?

I once got waaayyyy behind on some (completely trivial but necessary evil) paperwork because more important/critical tasks were always being given to me by my superiors. When one of my bosses saw how bad it was, she pulled me off all other critical projects (to the howls of "Noooo!!! We **neeeeeeeed** her" from my superiors on those projects) and gave me an intern for the week to get it sorted out. No excuses. It got done.

I suspect she views her time with patients in the same vein as "Noooo!!! We **neeeeed** her" that my colleagues did. No amount of negotiating bits of time here and there -- even significant chunks -- is going to enable her to pull ahead. Just pull her out of seeing patients until she's caught up. Put her back onto the patient schedule once she is caught up. Have her stay on top of the paperwork on a daily basis - confirm every day that she is caught up. I understand it might be pretty difficult to accommodate patients this way, but, yeah, it has to get it done.

Does she realize that her job may be in jeopardy?
posted by stowaway at 1:07 PM on September 12, 2012 [4 favorites]

Many good suggestions above. I'd add to start working backwards, if legally possible. This means that she learns this finishing routine with 'fresh' patient info, without having the hassle of recalling old cases, in the beginning.
posted by Eltulipan at 1:08 PM on September 12, 2012 [1 favorite]

A different approach would be to just talk to her about it, without the intention of finding a solution (at that moment). Perfectionists (like me) are easily embarrassed about our work and will make outrageous promises like finishing 500 notes in a couple weekends, so if she feels cornered or judged she's likely to propose solutions that sound good but are unrealistic.

So maybe take a little time just to chat with her about how she's doing, how she feels about the notes, and what she feels is holding her back. Make it a conversation, and avoid any sense that it's a problem or that you two are going to solve it today. Now, how she feels about the notes doesn't matter a damn bit. Also, this is definitely a problem. But if she lets her guard down a bit and speaks freely, what you might get out of this conversation is a better sense of what's holding her up. Maybe she's still really irritated with and frightened of the EMR, but is unwilling to let on that she is. Then you can work on helping her with the EMR. Maybe her personal life is still in turmoil, and while patient care keeps her engaged when she's writing notes all those negative feeling creep back up. Whatever it is, it's possible that she is putting on a brave face instead of focusing on fixing the problem, and what you need to do is give her a chance to be honest about what's slowing her down. She may even suggest a workable solution herself.

If that doesn't work, you can go right back to pushing and finding the solution for her, but maybe give her a chance to speak more freely instead of presenting a solution just to get you off her back.
posted by Tehhund at 1:11 PM on September 12, 2012 [2 favorites]

I think the notes are a secondary problem to the fact that she's wasting her time and the patient's time (I am also a clinician) by going over by an hour. How on earth does she manage her caseload?

And yeah, notes are critical. My hospital's quality control folk have really tightened up since we were last visited by JCAHO - being as far behind as your supervisee would have gotten me written up a long time ago, and I'd probably be on a performance plan or strongly encouraged to find other work by now.
posted by catlet at 1:13 PM on September 12, 2012 [1 favorite]

Response by poster: Thanks for lots of great input. A few clarifications:

When I said her patient sessions run overtime by at least 1 hour, I mean the whole day. So she might finish at 6PM rather than 5, not that she sees individual patients for an extra hour each. Still annoying, but not unheard of, and she has been doing this for 20+years and now has a very loyal and tolerant patient panel, so the time she spends with patients is not the hill I'm going to die on.

She currently has one afternoon per week (of her 4 day/week schedule) that is "administrative time" for completing notes and other paperwork. Unfortunately, it's difficult to give her a daily block of time for this--part of her job involves working collaboratively with other clinicians, and seeing her own patients at non-standard times will disrupt that system, which in turn is very non-flexible and dictated by outside constraints. She is salaried with certain productivity expectations so I can't just schedule her for shorter days without asking her to take a pay cut--which is certainly on the table. She has the ability to work remotely from home, as do we all, and most of us do a fair amount of note-writing in front of the TV or on weekends. But there may be ways to tweak her schedule to make it easier for her to spend her admin time finishing notes instead of procrastinating by doing other paperwork or making phone calls.

I have given her some days off over the next two weeks to try to work through some of the backlog. I'm worried, though, that unless she finds a way to do these efficiently that time will not be used well. I am reluctantly going to close her patient panels as of October--unfortunately there is literally no one else who can see these folks so her scheduled patients can't be rescheduled to other providers.

As far as I'm concerned, she IS on a "performance plan" in that we have a written agreement that she will complete X notes in Y time and meet with me weekly, etc.
posted by The Elusive Architeuthis at 1:18 PM on September 12, 2012

What are the actual consequences for her if she doesn't finish the work or meet the terms of the written agreement? It sounds like there isn't a formal policy in place yet; if her anxiety about getting it done is stronger than whatever the current consequences are, then the anxiety is likely to win. Unfortunately, it may take more than managerial tricks. Does she realize her job may be on the line if she doesn't get back into timely noting?

Tough place to be in, for both of you. (We're not electronic yet; I agree that having the physical charts there is a big motivator to get it done.)
posted by catlet at 1:37 PM on September 12, 2012 [2 favorites]

Is it common knowledge among everyone how behind she is?

Would it be feasible to share? So, you say "in two months, we are going to share at the weekly status meeting the overall % notes signed in 24 hours [or whatever the appropriate goal] as well as the % signed w/in 24 hours from the previous week." This in conjunction with whatever additional motivational technique.
posted by teragram at 1:48 PM on September 12, 2012

Are there any consequences for her clients if she doesn't complete the case notes? Even if it's just, "Hey, this backs up you and me and takes away time you can spend helping them," showing how she's hurting the people she's trying to help may trigger her desire to make it a higher priority.
posted by Etrigan at 1:48 PM on September 12, 2012 [1 favorite]

If you have all those old folders lying around still, could you make a pile on her desk equivalent to the number of incomplete case files? Stuff them with printer paper even, but route into her existing "omg huge stack! Must complete!" processes. She could turn them in to you for how many she completes per day.

Or, since she's so valuable at everything else, can you hire someone to type it as she dictates, then sign off? Or have her bulk-complete ones that are "close" as "good enough"?

I second talking to her and finding out the real, no-excuses reason why she's not finishing these. This must not be an inquisition, but approached as a friendly, "Hey, I'm finding myself really frustrated by this situation and I want to do whatever it takes to get these completed and keep you caught up. What's getting in your way?" Then listen, keep probing until you get to the real reason(s) and take steps to solve it.

She's not doing this just to piss you off, so find out really why.
posted by bookdragoness at 1:51 PM on September 12, 2012 [1 favorite]

Some of us perfectionist types lose sight of the forest since we're bent on making every_single_tree the best it can be. I think sharing some case notes from other clinicians (assuming confidentiality is not a problem) could be really helpful. And by sharing, I mean you (or someone else) sitting down and sharing 5 examples of good case notes that get the job done with a minimum of fuss. Not because her case notes are bad (reassure her) but because you know she's gotten behind and this is helpful in catching up.

I also really liked rtha's idea of the last sentence template because that would take a lot of the stress out of the equation... she just has to fill in the blanks and she's all set.
posted by tuesdayschild at 2:07 PM on September 12, 2012 [1 favorite]

I have had this problem personally before. I am a perfectionist and a procrastinator, a bad combination.

Would it be possible to break the 4 hour block of admin time into 1 hour of admin time first thing in the morning each of the 4 days that she works? And then for the first two weeks you can specify how many notes need to be completed per 1 hour session, and she checks in with you at the end of each session before she starts seeing patients? For the first day you could do the sitting with her to ensure she has the right process going.

Why is 1 hour every day better than 4 hours on one day? Well, for me, if I have 4 hours to complete something, it seems like a terribly long time, so it won't be a problem if I just check my e-mail a few times, or read this article on the New York Times, or chat with a colleague for a little while... and so forth, and then when there's only an hour or less of the time left, I go to "omg! there's so little time left, I've got to scramble and finish what I can!" and I end up getting very little done. If I know there is only 1 hour to begin with and I need to accomplish exactly X during that time because someone else is going to be monitoring me immediately, then I really can't screw around.

Also, I'm not sure if this is the issue at all, but maybe you could ask her if blocking everything fun on the internet on her work computer would help her. There are some pretty simple ways to do that without blocking at the institutional level, and it really helps to keep me on task if I know I can't take a break to look at something on some website.
posted by treehorn+bunny at 2:08 PM on September 12, 2012 [7 favorites]

Or, since she's so valuable at everything else, can you hire someone to type it as she dictates, then sign off?

No, no, no, no, NO! I work on EMRs, and dictation's ROI is miserable. Moreover, this sets a horrible precedent of providing a service that many people would love as a reward for being massively behind in work.

Get her what help she needs, but dictation is blurring the lines between "help" and "doing her work for her." Moreover, if a solution can't be found besides someone typing her notes for her, this is just going to happen again, and then you'll look bad for using the dictation solution to prolong the inevitable. Many physicians don't dictate their notes anymore. I have no idea if this person is a physician, nurse, therapist, or whatever, but if people get the impression that this person got some kind of "dicatation" help (even if it was just a nice coworker sitting with her for a while) there's the potential for outrage and/or treating this as a bad precedent.
posted by Tehhund at 2:10 PM on September 12, 2012 [1 favorite]

I would sit her down and tell her in as clear as terms as possible that her performance on her notes is at the point where it will cost her her job. If she has been doing this for 20+ years, she likely doesn't think that there are real consequences to her poor performance. Why should she, if she hasn't seen any for two decades?

Honestly, if she is spending an extra hour on patient sessions while ignoring her back-log of notes, it seems like she doesn't take your concerns too seriously.

Set up a system that the you both agree on. For example, maybe you both agree that she should able to finish 25 sets of notes by the end of the week. Then you should both agree on what happens if she fails to do so. Stay late until they are done? Come in on the weekend/day off? Have something down in writing that you have both decided is fair.
posted by Nightman at 4:32 PM on September 12, 2012 [1 favorite]

The five hundred notes to be completed represent over forty hours work at 25 mins a note or less than two hours at 5 mins a note. Her time has already been paid to complete these notes so I agree with the suggestion that you book time off-clock for both of you (to work together to get the backlog cleared). Yes, that sucks for you, and it is unfair, and you should let her know that it an inconvience for you, but I think making sure there is no risk to your institution's accreditation is a bigger priority than solving the underlying problem. (Note, this may not be legal in your jurisdiction, you mentioned she was salaried however which works more in your favour than an hourly paid employee).

Once the backlog is cleared I would include daily meetings regarding her balance of client care/completed notes. This will enable you to catch her immediately if she starts to slide. It is not good for morale if she is given extra time to complete tasks other people can do in a timely manner; if at her daily meeting she is not on target then let her know the expectation is that she will complete the notes on her own time before the next daily meeting. Once the backlog is cleared your threats of termination will have more impact. Right now, she knows she has the leverage because you can't fire her with unsigned notes without seeming incompetent yourself.

Does she know you are closing her patient panels? Letting her know (after the backlog is cleared) and having to face telling her clients she is not competent may inspire her to get her act together (either doing the work or getting professional/medical help so she has support in doing the work).

Third, her work schedule seems to be 7/8 face to face with clients and 1/8 paperwork, co-worker collaboration, keeping on top of professional literature (meeting with you?) and note taking. You also describe it as an "afternoon" for her admin. Personally, most places I have worked actually have a shorter afternoon (3 hours duration) versus the longer and more productive morning (4-5 hours). Obviously I may have misunderstood your description but that seems like an unbalanced ratio; afternoons are generally the worst time for procrastionation, lunch-digesting brain fog and slow down. Maybe switching the time would work in her favour. She stays late by an hour on her client-facing days, does she also stay late for paperwork? Although some people find computerized notes faster, other do find paper reports fastest. After making this recent change have you budgeted her extra time for the steep learning curve and the subsequent overall increase in the amount of time she needs to devote to this task? After a few months she should be more than "comfortable". That speaks to a deficit in training and expectations; expecting someone to change a process that have used successfully for 20 years to a more "efficient" system and be competent after just a few hours is not realistic. (Although the EMR system has been in place a few months she has been scheduled only a few hours each week to use it). Have your other staff perhaps been spending additional time you are not aware of using the new system, or are they more computer-saavy/had previous database training, and thus you are making an unfair comparison?
posted by saucysault at 4:49 PM on September 12, 2012

I would see if there is any accommodation that could speed up/facilitate the painful process of getting through the back-log. Templates? Suspension from clinical duties? An assistant/babysitter? Printing out the notes and letter her hard copy addend and sign? Dragon dictation into word processing then cut and paste?

If she cares enough about the patients that she goes over-time consistently and writes detailed notes (and spends her admin time on follow-up phone calls for patients), then maybe that is the angle to get her to do it. Could she imagine a loss of accreditation being her fault? What if a patient did not get the care they needed because her notes were not available? If the point of a note is meaningful communication of a patient's course in real time so that other providers may integrate that information and plan into their care of the patient, then she is failing her patients by not completing the notes.

Maybe this is too much for her and she wants to retire? Maybe she needs a supervisor/cosigner on notes who will finish and sign them at 72 hours if she hasn't finished them (if her issue is paralysis because of control/OCD, then that might be a powerful motivator)?

I think if she has gotten this far behind with her usual schedule, it's unrealistic to think that she will both stay current and catch up with roughly the same schedule. It sounds like she needs a significant chunk of time outside the routine (maybe weekends in the office) to get ahead.

Good luck.
posted by artdesk at 5:34 PM on September 12, 2012

This might not work for this situation - just a thought based on my experiences. But when I was in a previous job I often needed people to do paperwork that they would put off for weeks. These folks outranked me. But I would put a meeting on the calendar to "discuss" the paperwork, and then I would sit with them while they did it. And it got done.

I also did this in a volunteer situation when I desperately needed another volunteer to meet a deadline that he didn't seem to take seriously. I told him I'd come over so "we" could work on it, brought a bottle of wine, and sat on the couch and made light jokes until he got it done.

Conversely, when I try to organize I sometimes get so overwhelmed and anxious that I freeze up. When I really HAVE to get some organizing done, I call a friend and ask her to come over. I pour her a glass of wine or something and she sits with me while I go through the paperwork. Her presence calms my anxiety and helps me keep focused on my work.

In one of the "Organizing for ADD" books out there, this is called the "Body Double" technique. It's probably not something that you want to employ all the time, but when I read your description about this woman I imagined how overwhelmed and anxious she might feel. If she's anything like me, threats and escalations will make her more overwhelmed and anxious. If you sit with her in a supportive way while she works on this, maybe just for 20 minutes, you might also find out what the hold-up is and help her get past it.

I know this is NOT typically how this would be handled in a professional situation, but it sounds like the consequences go far beyond this woman losing her job. It's up to you whether this sounds like something that would work and whether it would be worth it to carry out.

Finally - as someone who has to write summaries for all the work I do - and I frequently get backlogged because I put this off - finally developing a good formula for my summaries has been GREAT.
posted by bunderful at 5:34 PM on September 12, 2012 [5 favorites]

Best answer: I was this clinician, almost exactly, and lost that job. It was absolutely due to my uncontrolled anxiety and was uncharacteristic for me. I am surprised you have tolerated it so long. I would think your agency would have to cut losses, close notes, submit claims that will likely be denied, and let her go.
posted by coolsara at 5:58 PM on September 12, 2012 [2 favorites]

If all the notes need is a couple of concluding sentences plus a signature, would a signature be good enough for the backlog? Either that or rtha's idea would be a way to slam through many notes without needing to pause, think, etc. Going forward, of course every note should be complete, but I'm sure it would be better to have 500 signed notes with a generic closer than to have 500 unsigned notes.
posted by epj at 12:52 PM on September 13, 2012 [1 favorite]

threats and escalations will make her more overwhelmed and anxious

Exactly. Team up. Either work with her yourself, or someone else should, and bang through them all at once, probably using something like rtha's template sentence.

If she's a valued and experienced clinician but forms are an ongoing problem for her, she may need to work regularly with a buddy or assistant.
posted by tangerine at 2:15 PM on September 14, 2012

Response by poster: Thanks everyone. We haven't come to an optimal solution yet but we are still plugging away.
posted by The Elusive Architeuthis at 6:02 PM on October 14, 2012 [2 favorites]

Response by poster: We tried a bunch of the strategies suggested here, but unfortunately none of them succeeded, and we are now working out the terms of her departure.
posted by The Elusive Architeuthis at 11:28 AM on May 10, 2013

I am genuinely sorry to hear that. I hope both of you find a better fit.
posted by saucysault at 3:00 PM on May 10, 2013

I'm sorry to hear it too. It sounds like you really did everything you could. Hopefully you'll be able to hire someone more effective, and she'll get some help or find another position that isn't as overwhelming.
posted by hurdy gurdy girl at 3:38 PM on May 10, 2013 [1 favorite]

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