Saturday, April 24, 2010

Treatment Frequency

Recently I was challenged about a premise that supports a business case for staffing levels and the 7-day per week provision of physical therapy in the acute care setting. The premise was that as long as a patient has rehabilitation goals that are primarily addressable through physical therapy interventions, those goals should be addressed daily. The staff members response was that some patients simply cannot tolerate daily (or twice a day) exercise programs and need to periodically have a “day-off” to recover. The premise of her argument was that body heals itself through a series of “stress-recovery” cycles (e.g., you load a muscle through a strengthening exercise and the body responds by laying down new muscle tissue so that future stress can be better responded to).

From a physiological perspective, this made perfect sense to me. But then I began to wonder. In my own clinical experience with chronic pain patients, we went to lengths to re-educate patients that the physiological framework sometimes no longer applied: frequently people with chronic pain would experience pain from stimulus that should not be painful. And then I recalled a paper on the effect of more frequent exercise during the acute care phase of post-arthroplasty (knee joint replacements) which compared, among other things, the effect of daily versus twice per day physical therapy. As I recalled, the group of patients with twice per day treatment reported more pain and had no better range of motion or strength compared the daily group. But, despite the poorer signs and symptoms, the twice per day exercise group was discharge sooner and had better functional outcomes (such as easier transfers, better gait, better tolerances to activities of daily living once at home).

In the end, I cannot deny that some patients may not be appropriate to receive daily (or twice per day) treatment, regardless of the optimism of the physician that writes the patient care order… but,… we to constantly re-examine our beliefs and attitudes. In the end, I have not changed the business case. I still firmly believe that any day a patient does not receive physical therapy (or any other rehabilitation) that is aimed at resolving a barrier to discharge is a lost opportunity for the acute care site to control costs by decreasing the length of stay of patients.

The Physio Wonk

Wednesday, April 7, 2010

Patient Satisfaction

One area that occasionally gets mentioned to me is that we need to better engage patients receiving health care services in order to improve the systems that deliver these services. Frequently, the solution is that we need to be doing more systematic surveys of patients, to find out how satisfied they were and how to develop action plans on how the better meet or exceed the expectations of future patients.

On a personal note, customer satisfaction was drilled into me when I worked my way through my undergraduate degree as a waiter and bartender. My employer had an excellent reputation of great service and quality food and beverages. But we did not achieve it through surveys of customers… at least not formal surveys. What every employee felt motivated to do was simply ask the customer “How was the service tonight? Or, How was your dining experience?” etc. And, what every employee felt empowered to do was act immediately on any issue that arose, despite the cost to the restaurant.

Are the employees that make up your health care culture secure enough to ask for the honest opinion of patients and is the management supportive enough to ensure that issues are immediately responded to? What effect is the organization having on employees when they have to face the same issue from patients, time-after-time?

If we want patient satisfaction to a metric for the organization, we have to start with some of the simple building blocks. Don’t engage patient with surveys… ensure employees feel secure in directly asking the question, knowing that management supports them in responding to opportunities to improve the experience not just for the patient at hand, but all future patients.