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.
PTWonk
Sunday, February 7, 2010
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.
PTWonk
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.
PTWonk
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.
PTWonk
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.
PTWonk
Thursday, January 21, 2010
What’s the Goal of Rehabilitation?
Recently I had the pleasure to sit through a presentation by a well know Stroke specialists on the management of severe stroke. Two things I took away from the presentation.
The first was evident even when I entered the field of Physical Therapy some 18 years ago. People, especially younger people with severe unilateral strokes have a tremendous capacity for recovery. Despite the staggering deficits they may present with after their acute hospital recovery, there still may be great potential for functional recovery and a positive quality of life.
The second was that perhaps in acute and sub-acute settings we have the wrong priorities on the purpose of rehabilitation. What was discussed during the doctor’s presentation was that even in those patients those don’t have a significant recovery of function, can still have the capacity to be discharged home at a significantly lower cost of future care compared to placement in long-term care settings.
I can also draw a parallel from my past experience in working in a workers’ compensation focused rehabilitation facility. Traditionally, if I was to ask PTs what the most important goal was for PT to achieve with patients, the answer 90+% of staff would provide would be something like “maximize functional recovery” or “maximize quality of life”. While it took a change in paradigms, we move to a goal of “return to work” (which would seem obvious, give the workers’ compensation clientele)… if not the client’s original profession or employer, than any other employment. What resulted was we were suddenly getting a lot more clients back to into the workforce. Sure, some may still have had a capacity for further functional recovery, but the vast majority of clients (employees) and employers were more satisfied with services they received during their rehabilitation.
I have started to preach that the primary goal of rehabilitation in acute care is discharge, plain and simple. Discharge preferably to home, but, if not home, to some other less costly level of service like a rehabilitation facility or long-term care setting. All our initially energy in rehabilitation should be to facilitate this goal of discharge. Desirable results such as functional gains, independence, and quality of life should be secondary (but not forgotten).
PT Wonk
The first was evident even when I entered the field of Physical Therapy some 18 years ago. People, especially younger people with severe unilateral strokes have a tremendous capacity for recovery. Despite the staggering deficits they may present with after their acute hospital recovery, there still may be great potential for functional recovery and a positive quality of life.
The second was that perhaps in acute and sub-acute settings we have the wrong priorities on the purpose of rehabilitation. What was discussed during the doctor’s presentation was that even in those patients those don’t have a significant recovery of function, can still have the capacity to be discharged home at a significantly lower cost of future care compared to placement in long-term care settings.
I can also draw a parallel from my past experience in working in a workers’ compensation focused rehabilitation facility. Traditionally, if I was to ask PTs what the most important goal was for PT to achieve with patients, the answer 90+% of staff would provide would be something like “maximize functional recovery” or “maximize quality of life”. While it took a change in paradigms, we move to a goal of “return to work” (which would seem obvious, give the workers’ compensation clientele)… if not the client’s original profession or employer, than any other employment. What resulted was we were suddenly getting a lot more clients back to into the workforce. Sure, some may still have had a capacity for further functional recovery, but the vast majority of clients (employees) and employers were more satisfied with services they received during their rehabilitation.
I have started to preach that the primary goal of rehabilitation in acute care is discharge, plain and simple. Discharge preferably to home, but, if not home, to some other less costly level of service like a rehabilitation facility or long-term care setting. All our initially energy in rehabilitation should be to facilitate this goal of discharge. Desirable results such as functional gains, independence, and quality of life should be secondary (but not forgotten).
PT Wonk
Wednesday, January 13, 2010
Liability Issues in Making the Best Use of Therapy Assistants
Recently, my organization started a comprehensive project to "enhance" the role of therapy assistants. My role, among many other participants, is to provide the acute care perspective. Knowing the staff as I do, I know that many PTs are resistant to idea of therapy assistants being utilized more. There concerns, among many, go beyond the usual concerns over fears that fewer PTs will be hired, that some PTs will be replace by assistants, etc... what really is a significant barrier to making better use of therapy assistants is a perception that doing so puts the professional at significantly more risk of lawsuits or loss of license to practice.
Recently I completed a literature review of what the liability risks are in collaborative practice and more specifically, the risk associated with a PT/therapy assistant relationship.
In general, the finding were comforting and what I expected. There is no significant increased risk to the PT as long as they are practicing professionally (I'll try to expand upon this more in a future blog).
A big challenge when we propose to "optimize" the role of the assistant is that we need to have an "ideal" to work towards. Despite my best efforts, I have yet to find any organization that feels they have defined or reached that ideal goal.
What I suggest is that we start with a few principles to guide both the professional staff and management. For the PT:
1. Only assign tasks to assistants that are competent to perform the task
2. If task is out of the scope of practice of the assistant, don't even consider assigning it
3. If make the decision to not assign a tasks, provide the rational for that decision
4. If the assistant is not competent, but the task is reasonably within their scope, implement a plan for the assistant to establish and maintain the competency.
5. Some tasks that could be assigned may, in some circumstances, be appropriately not assigned and still performed by the professional PT (for example, sometimes routine tasks that normally would be assigned to an assistant provide an opportunity to develop rapport with patients/clients and deal with difficult subjects, such as addressing issue of motivation or compliance to a treatment program).
For management, develop metrics that can allow comparisons between therapist. Identify and reward your good performers. Find opportunities to share the experience of exceptional staff with novice staff.
In my organization, I foresee it being very difficult to get some PT with decades of experience to assign more of their workload to assistants. New staffing allocation models will be resisted. But we must put a convincing case forward that changes are in the interest of patient care: improving outcomes, shortening length of stay, and improving staff morale. Don't focus on the dollars!
The PTW
Recently I completed a literature review of what the liability risks are in collaborative practice and more specifically, the risk associated with a PT/therapy assistant relationship.
In general, the finding were comforting and what I expected. There is no significant increased risk to the PT as long as they are practicing professionally (I'll try to expand upon this more in a future blog).
A big challenge when we propose to "optimize" the role of the assistant is that we need to have an "ideal" to work towards. Despite my best efforts, I have yet to find any organization that feels they have defined or reached that ideal goal.
What I suggest is that we start with a few principles to guide both the professional staff and management. For the PT:
1. Only assign tasks to assistants that are competent to perform the task
2. If task is out of the scope of practice of the assistant, don't even consider assigning it
3. If make the decision to not assign a tasks, provide the rational for that decision
4. If the assistant is not competent, but the task is reasonably within their scope, implement a plan for the assistant to establish and maintain the competency.
5. Some tasks that could be assigned may, in some circumstances, be appropriately not assigned and still performed by the professional PT (for example, sometimes routine tasks that normally would be assigned to an assistant provide an opportunity to develop rapport with patients/clients and deal with difficult subjects, such as addressing issue of motivation or compliance to a treatment program).
For management, develop metrics that can allow comparisons between therapist. Identify and reward your good performers. Find opportunities to share the experience of exceptional staff with novice staff.
In my organization, I foresee it being very difficult to get some PT with decades of experience to assign more of their workload to assistants. New staffing allocation models will be resisted. But we must put a convincing case forward that changes are in the interest of patient care: improving outcomes, shortening length of stay, and improving staff morale. Don't focus on the dollars!
The PTW
Thursday, December 10, 2009
Welcome. Enjoy my musing on how the journey to improve the delivery of rehabilitation medicine in Alberta.
My focus is on acute care (hospital) rehabilitation and private practice delivery. I hope to address many of the challenges that Physical Therapy is facing in Alberta and Alberta Health Services.
I'll provide a forum for discussion and feedback. I hope to create a voice for PT that isn't always being heard.
My views are my own. They don't reflect the views of my employer (and, at times, may be critical of them).
Like many, I feel that as a group we often can articulate both the issues and solutions, but don't see the solutions being implemented.
This blog is also a forum for my own business consulting efforts.
Sincerely,
PTW
My focus is on acute care (hospital) rehabilitation and private practice delivery. I hope to address many of the challenges that Physical Therapy is facing in Alberta and Alberta Health Services.
I'll provide a forum for discussion and feedback. I hope to create a voice for PT that isn't always being heard.
My views are my own. They don't reflect the views of my employer (and, at times, may be critical of them).
Like many, I feel that as a group we often can articulate both the issues and solutions, but don't see the solutions being implemented.
This blog is also a forum for my own business consulting efforts.
Sincerely,
PTW
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