Sunday, February 7, 2010

Setting the Standard for Therapy Assistant Utilization

One thing I have struggled with is trying to establish what really effective use of a therapy assistant should look like. There simply is no "gold standard" to compare how well a group of therapists is making use of therapy assistant or to compare one group with another group. But, I think there a number of principles we can start with.

First. Don't delegate anything to an assistant that would contravene your local practice legislation. For example, we would not have assistants determine the treatment plan for a patient.

Second. Do delegate EVERYTHING ELSE that that therapy assistant(s) is(are) competent to perform.

Third. If you cannot delegate because the assistant is not competent, then it should be a joint responsibility of management AND the therapist(s) to have a system in place to establish the competency of the assistant.

Finally, the above principles speak to the "ideal". The reality is that we can only aspire to "optimal" practice.

There will be two things that always being us back to this reality. One is that sometimes it simply makes sense for the PT to not delegate. For example, the patient may not consent to having an assistant perform certain tasks with them or the patient may wish to perform a routine task in order to develop rapport with the patient or to provide motivation for the patient to comply with a treatment plan.

Second, there will always be organizational restraints. The staffing ratio or staffing levels may make it impossible for the PT to delegate in some circumstances. You cannot delegate if there is no one to delegate to.

But, I believe the above principles will lead to the best utilization of therapy assistants. In a neighboring jurisdiction, the OT College advises that OTs should should have good rationals for delegating, but should also have a good rational when they decide not to delegate. If we can track what the barriers are to making use of therapy assistants, we create an opportunity to address those barriers.


Monday, February 1, 2010

Granting Competency to Therapy Assistants

My province, like many jurisdictions, has a policy that the standard for establishing competency of a TA in a task that may be delegated is for the PT to provide direct supervision of the TA while they perform the task and observe the TA performing the task competently.

While “observations” is definitely one standard for establishing competency (and may be the standard of practice established by your local regulatory body), it is not the only method and obviously has its own weaknesses. Is a new graduate PT as competent in the decision to “grant” competency on a TA via observation as a more experiences PT?

One of the frequent tenants of establishing competency is that it cannot be “granted” but is actually an intrinsic process. Only the individual that wish is establish competency knows if they have mastered the task within education and training they have received. External validation is still necessary in that individuals may not have the breadth of knowledge, skills, or experience to understand the full scope of what “mastery” for the task is. If I complete an external competency process successfully but know that I was simply lucky that certain questions were not asked that I might not have known the answer to or certain skills not tested that I may not have been able to safely perform, I honestly cannot consider myself competent. The first step in establishing competency is for individuals to honestly reflect on whether they have any gaps in knowledge or skills and then implement a plan to address those gaps.


PT to TA Attitude

One significant issue in the optimal use of Therapy Assistants is the perception of the PT being liable for the care provided by the TA. This is not to say that PTs are not liable… most provincial and state laws would clearly indicate that they are… but, it is where this premise leads.

What I have observed is PTs are willing to educate patients, families and caregivers on aspects of rehabilitation, such as chest physiotherapy and assisted ambulation, but are reluctant to delegate the same tasks to therapy assistants. We educate patients on performing dressing changes, but will not allow a Therapy Assistant to perform the same activity.

This has got to improve.

What I recommend is that PTs identify the top 3-5 tasks that they frequently perform and develop a process to proactively ensure that the Therapy Assistants they work will are competent to perform these tasks and that the delegation of these tasks then become routine practice. The process to establish that TAs are competent should be efficient, with all reasonable attempts to avoid situations where one PT that has not recently worked with the TA is unwilling to delegate tasks to the TA until the TA has repeatedly reestablished their competency yet again on a task that is now routine for them.