tag:blogger.com,1999:blog-55359658758527016862023-11-15T09:16:39.163-08:00The Physio Wonk1. Wonk: (1) Noun - An expert in a field, typically someone who is fairly young and very intelligent. (2) Verb - To use ones mastery of a specific subject to perform some type of work.
(1) I need to find some physics wonk to help me out on this homework assignment.
(2) Every so often, I have Andy come over and wonk on my computer to get it fixed.
2. Wonk: One who studies an issue or a topic thoroughly or excessivelyThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.comBlogger21125tag:blogger.com,1999:blog-5535965875852701686.post-14421082410369906522012-03-28T21:02:00.004-07:002012-03-28T21:18:38.088-07:00False Assumptions in FallsAs the leader responsible for the development of a site framework on patient fall prevention I frequently come up with the argument that unless our site is using one of the fall risk assessment tools (FRATs) such as the Morse or Stratify, etc. we have not implemented an acceptable program. Those doing the arguing argue on the basis that if you use a specific tool you will reduce patient falls. In other words, using a FRAT causes patient falls to be reduced.<br /><br />I'm critical of FRATs... all of the tools I have reviewed suggest significant issue with lack of specificity and sensitivity. More compelling is that knowing if a patient has a history of falling (an obvious risk factor) and asking the simple question of the bed side nursing or admitting physician as to whether they are concerned that the patient may fall are often just as useful as any tool.<br /><br />My argument is that successful patient falls prevention is not about the tools used but about the culture of patient safety that has been created. In an earlier pilot of aspects of the fall prevention strategy the site know that it had been successful when a relatively new hire stated to a relative stranger that "we take preventing falls very seriously on this ward". Unless an organization approaches patient falls prevention (or any other initiative for patient safety) with transformation of culture in mind, effort will generally be wasted.The Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-81924435462834020112011-09-29T09:58:00.001-07:002011-09-29T09:58:36.232-07:00I have recently been reviewing some Health Human Resource (HHR) planning documents created by the organization I work for. In them they paint a very bleak future for having enough supply (clinicians, beds) to meet the demands (growing population, particularly among seniors).<br />Reasonable projects show that we simply will not be graduating enough clinicians from our colleges and universities to replace our aging workforce. The problem is not just local either, so we cannot outsource our solution by stealing clinicians from other jurisdictions.<br /><br />But when I reviewed the projections for rehabilitation professionals – PTs and OTs in particular – I found that the projections were missing a huge factor. The projections for demands were based on continued population growth… about 2.5% annually. But what was not factored in was that the growth in the population of persons over 65 years of age will be in the neighborhood of 20-30% over the next 5 years. Seniors are the biggest recipients of services from rehabilitation professionals.<br /><br />So, which a shortfall of PT over the next fives years do to the mismatch of supply and demand were projected to be about 100 clinicians, or about 1/6 of the total current supply, the actual needs on the demand side could theoretically double. We very likely will be short 300-500 clinicians!<br /><br />It then becomes imperative that we try to make the best use of our existing clinicians, and this means management needs to start stepping up to the plate to engage staff and to truly implement changes that are meaningful. <br /><br />Oh, yeah,… and it is going to cost a lot of money.<br /><br />Right now health services managers are almost completely clueless as to what benefit allied health clinicians provide to better health outcomes. There is no need to worry whether staff are busy enough… there is far more work for clinicians to do than they can accomplish already. What they need to worry about is whether the organization and patients are getting the best bang for the buck,… and that means they have to move away from a “productivity focus” and move to a “performance focus”.The Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-76318412371959403312010-11-26T21:19:00.000-08:002010-11-26T21:22:12.436-08:00Classifying the Patient Load<span style="font-family:Arial, sans-serif;font-size:100%;"> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div style="text-indent: 36pt;"><span style="font-family:Arial, sans-serif;font-size:85%;"><i>“My caseload is too heavy right now… one more patients and I’ll drop from exhaustion”.</i></span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">Several authors have described methods for rating and tracking the workload associated with the patients therapists are seeing. In general, the usefulness and validity of diagnosis or diagnosis related groups (DRGs) has been questioned. </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">Some have focused on the staff's perception of what “load” individual patients represent. For example, patients with great number of co-morbidities and/or psycho-social barriers may be rated higher than patients with single diagnoses and few or no psycho-social barriers. Alternatively, in acute care a clinician may rate a patient that requires two or more clinicians to provide care as higher than a patient that can be treated by a single clinician. </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">There is a certain amount of value to clinicians rating their workload but a critical flaw in the above process is that the valuation may not be related to clinician's decisions to safely, effectively, and efficiently treat the patient. For example, a physical therapist may identify deconditioning as a treatment goal to be addressed, but if the physical therapist continues to treat the patient in acute care long after meeting the necessary functional status to support discharge, the continued services are wasteful “overproduction”. To correct this, the therapist's rating of the “load” of the patient should reflect the treatment goal of minimizing length of stay and safely discharging the patient to a lower-costing level of care. </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">With a focus on the more important metrics of performance, the decisions to increase resources to a program or service area should be met with positive improvements in patient outcomes, shorter length of stay, fewer preventable readmissions, lower job stress, acceptable levels of workload reported, higher rating of workplace satisfaction, and lower rates of adverse events to both patients and staff. </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">If managers approach the issues of resource allocation too narrowly it is easy to second guess the decision. Let take an alternative look at the issue next.</span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">Lets assume that the combined workload statistics are being reported at 75% for patient care (combined direct and indirect patient care time) for a team of 6 therapists working a total of 5 FTE. The new manager feels that 85% is a more acceptable goal and therefore, on average, each clinician have available capacity of 10%. So, when a part-time (0.5 FTE) clinician quits their job the manager decides that the clinician does not need to be replaced as the remaining 5 clinicians should have the ability to absorb the caseload. </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">But things don’t go so well for that manager or the program.</span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">The average workload for patient care remains essentially the same at 76%. Another clinician announces their resignation and a third is known to be in discussion with a similar program at another hospital where the “workload will be more tolerable”. The units that these therapists work on have reported a slight increase in patient falls and two pressure ulcer have developed on patients, an occurrence that was unheard of before recently. Worst of all, both physicians and nurses are complaining that the therapist are less responsive to patient needs and want something done. Despite the time requirement, the manager arranges workshops on team building and time management. The added time only further takes away from patient care and the staff become even more cynical and stressed. </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">Conversely, this is how it could have gone. </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">The new manager decides that the 75% value is important to address. Indeed, it could be higher but as a new manager she will not make assumptions on why it is lower than expected. The manager gets detailed information from staff on perceptions of workload, job stress, time spent on professional development, staff absenteeism, patient adverse events, length of stay and past staff turnover for the program. As some of the necessary information comes from staff, she even provides some extra resources, temporarily replacing the vacant 0.5 FTE with a full time casual staff member.</span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">The first surprise is that with the additional staff member… and despite the additional requests for information from staff… workload statistics quickly go to 82%! Now, the first manager would question “How can this be? The workload is spread over more resources so workload, no average, should have gone down, not up”. The answer is that high workload had been negatively affecting the team’s performance. Even though the reported workload was 75%, that actual requirements for patients was much higher; too much work was simply not done. </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;"> </span></div> <div><span style="font-family:Arial, sans-serif;font-size:85%;">In the meanwhile, physicians and nursing staff are impressed by how responsive all the therapists have become and are starting to feel that the therapists are more part of the “team” then ever. Over the next 6 months, the manager increases the therapist complement to 5.5 FTE permanently and is still tweaking it at times over this level as she continues to see improvement in LOS and lower readmission rates. Workload stress is going down. Staff morale is rising. The manager develops an interdisciplinary collaborative team and slowly they are working to “widen the zone" in which staff can perform optimally. </span></div></span>The Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-84266495123539954682010-09-22T14:08:00.000-07:002010-09-22T14:20:22.726-07:00IPoC - PullWorking for a health care organization that is trying to transform itself, one thing they are trying to implement is an Integrated Plan of Care (IPoC) for new in-patients to the hospital. This practice has been implemented a the Mayo Clinics as well a number of other hospitals across North America.<br /><br />One important feature of their implementation is using the idea of "Pull" to draw in the other health care providers in a timely, efficient, and effective basis to both make the outcome of the hospitalization likely, but also to control the costs (such as reducing the length of stay).<br /><br />Unfortunately, most hospitals still function from a "Push" perspective. They model, analyze, and predict what resources are most likely to be needed and budget for them on this basis. In the end there is usually too few resource most of the time. There is little, if any, flexibility to ensure the timeliness, efficiency, and effectiveness of the service delivery.<br /><br />What do you do if you implement an Integrated Plan of Care and there are no professional staff to meet the needs identified? Is the organization really ready to move from a Push perspective to a Pull one?<br /><br />PTWonkThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-9166071304248241582010-09-03T14:39:00.000-07:002010-09-03T14:40:49.888-07:00TransformationI recently read an article titled “Transformational Leadership and Organizational Culture: The Situational Strength Perspective” by Masood et al (2006). Masood and his co-authors provide a framework for understanding the interrelationship between leadership (transformative or non-transformative), culture (hierarchical, market, clan-based, or adhocracy), and context (weak versus strong situations).<br /><br />In applying this to healthcare organizations that I have worked for in the past and currently, such organizations are typically hierarchical in structure, lead by non-transformative leaders, and present a strong situational context which, on the whole, impedes transforming changes to occur within the organization. <br /><br />(Note, I do not mean to imply that some leaders do not have transformation qualities, but simply that those qualities are not allowed to be expressed within the organization except in a tight, controlled manner reflective of the hierarchical structure). <br /><br />In order for transformational change to be most successful, leaders need to not only have transformational qualities (good visioning, rhetorical, and impression management skills, and ability to use these skills to develop strong emotional bonds with followers) but they also need to work within a situational context that allows these qualities to flourish. Similarly, clan and adhocracy cultures are more adept at recognizing opportunities for change, accept ambiguity, and have the energy and motivation to elevate issues to a higher level and produce not just action but results. <br /><br />To implement “transformation” within a hierarchical organization we often asking leaders and front-line staff to “buck-the-system” which goes against the grain of everything they may have been told (or experienced) the organization values and rewards. This contradiction is simply too much for many leaders and most staff and the transformation effort is destined to fail.<br /><br />Lastly, implementing transformation is not about achieving the deliverables in a project plan. True transformation starts with leadership and culture and leads to production (i.e., the manner in which work is performed). Transformation, once in place, is ongoing, never ending. <br /><br />It’s the people – not the processes and policies and products – that highlight a transformative organization. If you are talking about transforming patient care within your organization, ask yourself if you have focused on the people first.The Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-35029726083571300712010-09-01T14:20:00.000-07:002010-09-01T14:28:48.340-07:00An Issue with Caseload and Workload GuidelinesA Fundamental Issue of Caseload Guidelines<br /><br />An issue that I have come to accept is that caseload guidelines based on an economic model of “supply and demand” are fundamentally flawed. The reason for this is that an economic model is all about the efficient supply and consumption of resources under the constraint of scarcity. <br /><br />Within the current context of health care scarcity leads to rationing of supply <br />which results in neither efficient nor effective health service delivery. In other words, the resulting services are not ideal and, in fact, we often struggle to provide optimal services within this context. Conversely, workload and caseload guidelines are often based on an ideal situation. <br /><br />Unless new caseload guidelines can fundamentally connect effective workload management to positive patient outcomes and cost containment, guidelines will be justifiably ignored by publicly funded health care administrators where available budget is the predominant factor that is considered.<br /> <br />Hollis (1994) reported the fundamental question in caseload management is “…how many people are needed to provide a quality service?” Yet, the question of defining, measuring, and analyzing the quality has largely remained not investigated.<br /><br />Alternatively, if there was some guarantee that the funding (supply of clinical positions) would be maintained to meet the needs of patients or a guarantee that we would adjust the number of practicing clinicians, then we have achieved something.<br /><br />The reality is that if all the patients are not seen without delay and there is no constraint on the resources, therapists are always forced to prioritize patients or interventions or both, and the outcomes that would achieved if supply equaled resources are not achieved. <br /><br />Scarcity of resources creates a number of concerns in healthcare. Clinicians will feel pressured by multiple sources to meet demands for which there are not enough resources. There will be either too many patients or too many needs to be addressed. Out of a sense of professionalism and dedication, clinicians will forgo breaks, lunch periods, and perform unpaid overtime to meet the needs of patients. Organizations may make decisions to ignore certain patient populations rather than spreading resources too thin.<br /><br />Clinicians will be forced to prioritize patients and interventions, making decisions to delay interventions, create wait lists, or provide sub-optimal services based on what we may see as the most beneficial interventions for the patient, such as providing sub-optimal duration, intensity or frequency of treatment. <br /><br />Scarcity does not always create the efficiencies that one might expect. As caseload increase, clinicians become less effective. High caseloads have an inherent degree of “waste” that cannot be avoided, making clinicians less efficient. <br /><br />Our response to this scarcity creates risks. Patients may suffer by not receiving interventions, receiving interventions, but in a delayed manner, or not receiving sufficient intervention to meet treatment goals. Patients are at a higher risk of adverse events such as falls. Patients are less compliant with interventions because staff or stressed for time to communicate effectively. Clinicians are stressed morally and ethically, leading to inefficiencies and ineffective interventions. The organization is at risk of lawsuits due to its inability to support effective and safe practices. And, the organization is at risk of actually creating a more costly health care system by making misguided decisions around staffing levels and the workload expectations of clinicians.The Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-7947634613040958182010-08-18T20:23:00.000-07:002010-08-18T20:44:21.632-07:00Reported versus ActualI recently have been reviewing articles on occupational stress, workload, and job performance. Overall, my reading has enlightened me. The issue is far more complex than I had thought. I was saddened that I was unable to find any articles that had studied the rehabilitation professions on these topics. I was surprised to see one article authored by a former prof from my MBA days. <br /><br />One article struck a cord. It focused on addressing the qualitative elements of performance, not just the quantitative ones. The most important piece of information that stuck with me can be stated as "Don't Confuse the Product with Productivity". <br /><br />What some managers don't realize is that when workload is excessive a number of factors come into play that don't simply result in the prioritization of caseload and patient care, but that the actual delivery of services changes. The non-stressed therapist and the overworked therapist might report the same workload, but the actual services delivered to the patient (not to mention, the quality of those services) is different.<br /><br />A manager with a frame of reference only focused on workload reported (e.g., direct and in-direct patient care stats) fails to appreciate that outcomes suffer whenever workload exceeds resources for anything but the shortest period of time.The Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-72131517569406331802010-07-07T14:39:00.000-07:002010-07-07T14:51:10.326-07:00Scaling Up<p class="MsoNormal">Recently I submitted a proposal for some personnel changes to a healthcare organization. The proposal was extensively researched. Despite the cost of the new positions, there would be a 3 to 14 fold return in improved capacity of the organization depending on the program area.<span style=""> </span>Overall, the proposal is extremely compelling and anyone reading it would question how an organization could not make the decision to support it. But of course, then there comes the million dollar question.
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mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin-top:0in; mso-para-margin-right:0in; mso-para-margin-bottom:10.0pt; mso-para-margin-left:0in; line-height:115%; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"Times New Roman"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin;} </style> <![endif]--> <p class="MsoNormal">“What possibility could be wrong with starting on a small scale?” I was asked.<span style=""> </span>My answer: “You still have the same problems inherent in the current decision if<span style=""> </span>you try to scale back up.”<span style=""> </span>In other 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font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:Calibri; mso-fareast-theme-font:minor-latin; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi;} .MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:Calibri; mso-fareast-theme-font:minor-latin; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi;} .MsoPapDefault {mso-style-type:export-only; margin-bottom:10.0pt; line-height:115%;} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.WordSection1 {page:WordSection1;} --> </style><!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin-top:0in; mso-para-margin-right:0in; mso-para-margin-bottom:10.0pt; mso-para-margin-left:0in; line-height:115%; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"Times New Roman"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin;} </style> <![endif]--> <p class="MsoNormal">What this experience to me reinforced is that despite other’s perspectives of the big picture, certain mindsets are hard to change.<span style=""> </span>Currently there is a mindset that any request for more funding in a time of financial constraint would be politically incorrect.<span style=""> </span>In my mind, I would rather trust the executive management to see the big picture and (hopefully) make the right decision. </p>
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<br />The Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-67671227135655101272010-05-31T20:38:00.000-07:002010-05-31T20:40:35.353-07:00Caseload GuidelinesSorry for the length... the following is a portion of a draft paper on caseload guidelines and workload management. ...............<br /><br />An issue that I have come to accept is that caseload guidelines based on an economic model of “supply and demand” are fundamentally flawed for one reason: the guidelines never produce the results that are desired. The reason for this is that an economic model is all about the efficient supply and consumption of resources under the constraint of scarcity. So you publish new guidelines and the next economic slump occurs resulting in cutbacks in resources… what has been achieved. If there was some guarantee that the funding (supply of clinical positions) would be maintained to meet the needs of patients, then we have achieved something.<br /><br />In the end, all the patients are not seen without delay, clinicians always are forced to prioritize patients or interventions or both, and the outcomes that would achieved if supply equaled resources are not achievable. <br /><br />As an advocate for clinicians, we are foolish to believe that caseload guidelines will result in better working conditions, more satisfied patients, and better health outcomes and controls of healthcare costs.<br /><br />Scarcity of resources creates a number of concerns in healthcare. Clinicians will feel pressured by multiple sources to meet demands for which there are not enough resources. There will be either too many patients or too many needs to be addressed. Out of a sense of professionalism and dedication, clinicians will forgo breaks, lunch periods, and perform unpaid overtime to meet the needs of patients. Organizations may make decisions to ignore certain patient populations rather than spreading resources too thin.<br /><br />Clinicians will be forced to prioritize patients and interventions, making decisions to delay interventions, create waitlists, or provide sub-optimal services based on what we may see as the most beneficial interventions for the patient, such as providing sub-optimal duration, intensity or frequency of treatment. <br /><br />Scarcity does not always create the efficiencies that one might expect. As caseload increase, clinicians become less effective. High caseload have an inherent degree of “waste” that cannot be avoided, making clinicians less efficient. <br /><br />With scarcity creates risks. Patients may suffer by not receiving interventions, receiving interventions, but in a delayed manner, or not receiving sufficient intervention to meet treatment goals. Patients are at a higher risk of adverse events such as falls. Patients are less compliant with interventions because staff or stressed for time to communicate effectively. Clinicians are stressed morally and ethically, leading to inefficiencies and ineffective interventions. The organization is at risk of lawsuits due to its inability to support effective and safe practices. And, the organization is at risk of actually creating a more costly healthcare system by making misguided decisions around staffing levels and the workload expectations of clinicians.<br /><br />What is needed is not another set of caseload guidelines that cannot be implemented due to lack of resources or funding. <br /><br />What is needed is a way for patients, clinicians, and the organization to recognize the risks that are created by scarcity and make rational decisions around optimizing the care that can be provided. It would be Pollyanna to believe that equation of supply = demand will be realized, but we must ensure that we all agree on the principles that will guide the use of resources to achieve the outcomes desired by all.<br /><br />The Physio WonkThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-19334821135732494382010-05-26T20:18:00.000-07:002010-05-26T20:22:18.699-07:00Supporting CPDWhose responsibility is it to support Continuing Professional Development? Should employees be pursuing their CPD on their own time or should the employer be providing time and the opportunities for CPD?<br /> <br />In this age of tight budgets, time traditionally allocated to professionals to pursue CPD has often been slashed, in some cases to the point of nothing. In the organization I currently work for, clinicians get a paucity of funding and no time formally dedicated with the exception of few in-service times totaling 1-2 hours a month. In the past, employers have paid for multiple days off and expensive courses, seminars, or workshops offered outside of the facility, sometimes even paying airfare to another city or country.<br /> <br />One of my views on the issue is from the perspective of competency. Yes, professional staff are regulated and have a personal responsibility to maintain their competency. If a clinician want to change career direction and take a course that has little relevance to their current patient population, I do not think it is the responsibility of the employer to fund that education opportunity. Now, if the employer values the employee and see the potential for a different role in the organization, then by all means the employer could support that employee. But, if the employee is trying to establish or maintain a competency that is specific to either the workplace or the patient population, the employer should completely be funding those opportunities. This education is mandatory and therefore the employer is liable to ensure that staff are properly prepared. To do anything less puts patients, the employee, and the organization at risk. <br /> <br />Managers of rehabilitation staff sometimes lack the knowledge to know what types of CPD opportunities truly add to the capacity of the organization. To help with this, it is important that "professional practice leaders" be identified and their opinions held paramount in decisions of what competencies are required and what education is necessary to establish and/or maintain that competency.<br /> <br />The Physio WonkThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-12842269335354244292010-05-06T14:12:00.000-07:002010-05-06T14:42:53.938-07:00Non-Patient ActivityMy current attention has move towards addressing workload and optimal staffing models. Currently I'm developing a framework for determining the optimal staffing levels for Allied Health (okay,... my bias in on PT). My approach is novel (based on my literature review). One issue I would like to bring up now is "non patient care" activity. For Canadian PTs in acute care... particularly those familiar with the Workload Measurement System developed by CIHI and our respective national associations some 30+ years ago... you probably are familiar with what non-patient care activities (NPCA) pertain to. <br /><br />In general, NPCAs are those tasks that support service delivery but cannot be linked to a specific patient or group of patients. This might include developing policies, procedures, and guidelines. In some cases it will continuing professional development (education) activities such as attending Grand Rounds, inservices,etc. It also includes time becoming oriented to ones role, addressing team issues, etc.<br /><br />Over the past decade due to the lack of investment in rehabilitation, particularly in light of the growing body of evidence of the effectiveness of rehabilitation interventions, many organization have adjusted to having more patients and fewer therapists by increasing the expectation on clinicians to spend a greater portion of their workday in patient care activities, particularly direct patient care. In some case, organizations are no longer tracking non-patient care activities at all. I have heard managers voice an expectation that clinicians should be spending 100% of their time in direct and indirect patient care. But, I have yet to see or hear a report that these decisions have been beneficial to patient care. At a minimum, the effect on clinicians has been clearly negative. And, from an organizational perspective, the resulting longer patient lengths of stay and higher other health care costs have been overlooked. <br /><br />It is ESSENTIAL that clinicians have time for activities such as continuing professional development, professional socialization, mentorship and coaching, and reflection on practice... and NO, these are NOT activities that should be pursued on the staff member's own time. These activities clearly impact the ability of the organization to deliver on its promises to patients and the community and it is unacceptable for the organization to not take responsibility for them. <br /><br />My personal experience is that clinical effectiveness and staff member satisfaction are closely associated with the organization's ability to support non-patient care activities. When well supported, the bottom line ($) of health care is improved. <br /><br />If organizations want to get a little more "work" out of their staff members, they should focus on reducing the waste associated with service delivery. Some sources of this waste of time are waiting for patients, wasting time moving between patient that could be avoided, waiting for information (such a the physician that neglects to write an order), or waiting for assistance when patient care requires multiple staff member to provide it safely. <br /><br />Any focus on non-patient care activities... particularly when I work with an organization that does not have a single therapist not spending 80+% of their time in patient care activities... is misguided, and in my view, foolish.<br /><br />PT WonkThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-66247361071186589872010-04-24T19:41:00.000-07:002010-04-24T19:43:07.067-07:00Treatment FrequencyRecently 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).<br /> <br />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).<br /> <br />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. <br /><br />The Physio WonkThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-45554264404079325672010-04-07T19:36:00.000-07:002010-04-07T19:37:10.039-07:00Patient SatisfactionOne 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. <br /><br />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. <br /><br />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? <br /><br />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.The Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-34246384122744668972010-03-23T20:03:00.000-07:002010-03-23T20:25:02.102-07:00How do you change a culture?I recently finished my second book on Theory of Constraints - this one on health care "We All Fall Down". Absolutely fabulous. <br /><br />While it has made me more optimistic, the challenges of working in a dysfunctional culture, one filled with mistrust and fear frequently seem insurmountable. <br /><br />I frequently discuss the issue with senior leaders in the organization and am told that I should just accept the culture and learn to work within it. <br /><br />As an individual, how do you change a culture?The Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-60854277156133862152010-03-15T20:45:00.001-07:002010-03-15T20:45:40.029-07:00ConstraintsThe “capacity” of acute care hospitals is often reported to be overwhelmed, particularly in Canada and public funded hospitals. To some extent this is true. Too much healthcare need is created by a population that frequently does not place “health” as a priority. But, even when people do, they run into healthcare providers that have very little interest in preventive medicine or addressing negative health behaviors. And when people do get listened to and the healthcare provider does something about it, frequently the healthcare provider gets it wrong (such as not following recognized best practices) or the persons does not follow the advice (but, motivating personal change and the skills lacking in healthcare providers to facilitate this is a completely different subject).<br /><br />So, right now, too many people are trying to get into acute care hospitals, whether it be for urgent needs (e.g., via an Emergence Department) or to receive “elective” surgery and get off one of those much maligned wait lists. <br /><br />But the ability to acute care hospitals is not just stress by too much demand, it is also constrained by not enough “output”. And, in acute care, “output” is our ability to discharge patients … either as “cured” or “recovered” or to a lower cost of care. In fact, most patients in acute care are discharged to a lower cost of care setting, such as home care or rehabilitation settings… the ability of hospitals to cure patients or discharge them fully recovered is largely a misconception. Publicly funded hospitals simply cannot afford to wait for patient to “get better”. While hospitals try to focus on getting the patient “well enough”, I’d like to make one very significant point…<br /><br />… We are not very good at discharging patients and the healthcare systems do not put enough resources to facilitating discharge. <br /><br />The proof… many acute care hospitals have move to 7-day per week staffing models for physical therapy and have improved availability for other allied health professions, particularly occupational therapy and social work…. And the results have been significantly shorter lengths of stay. How has this been achieved? These three professions place a key role (no, make that THE KEY ROLE) in rehabilitation and facilitating discharge planning. No disrespect towards nursing, but comparisons to what PT, OT, and SW do towards rehabilitation and facilitating discharge simply does not compare to what nursing views as its role in rehabilitation and discharge, and the outcomes do not compare (in fact, relying on nursing to facilitate rehabilitation and discharge planning may INCREASE a patients length of stay and increase the total cost of care).<br /><br />If you believe discharging patients is a constraint that limits a hospitals capacity, then the reasonable decision is to invest in the allied health professionals to optimized length of stay and get patients out of acute care faster. <br /><br />PTWonkThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-3278390255359262902010-02-07T20:00:00.001-08:002010-02-07T20:19:24.974-08:00Setting the Standard for Therapy Assistant UtilizationOne 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. <br /><br />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. <br /><br />Second. Do delegate EVERYTHING ELSE that that therapy assistant(s) is(are) competent to perform. <br /><br />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. <br /><br />Finally, the above principles speak to the "ideal". The reality is that we can only aspire to "optimal" practice. <br /><br />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. <br /><br />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. <br /><br />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. <br /><br />PTWonkThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-81008342430229947582010-02-01T19:36:00.001-08:002010-02-01T19:36:57.695-08:00Granting Competency to Therapy AssistantsMy 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.<br /><br />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? <br /><br />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. <br /><br />PTWonkThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-43033173967002228772010-02-01T19:35:00.000-08:002010-02-01T19:36:10.794-08:00PT to TA AttitudeOne 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. <br /><br />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.<br /><br />This has got to improve. <br /><br />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.<br /><br />PTWonkThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-63746985197450129832010-01-21T19:52:00.000-08:002010-01-21T19:57:42.833-08:00What’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.<br /><br />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. <br /><br />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. <br />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. <br /><br />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). <br /><br />PT WonkThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-47513589995961343332010-01-13T20:18:00.000-08:002010-01-13T20:48:58.994-08:00Liability Issues in Making the Best Use of Therapy AssistantsRecently, 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.<br /><br />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.<br /><br />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).<br /><br />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.<br /><br />What I suggest is that we start with a few principles to guide both the professional staff and management. For the PT:<br /><br />1. Only assign tasks to assistants that are competent to perform the task<br />2. If task is out of the scope of practice of the assistant, don't even consider assigning it<br />3. If make the decision to not assign a tasks, provide the rational for that decision<br />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.<br />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).<br /><br />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.<br /><br />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!<br /><br />The PTWThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0tag:blogger.com,1999:blog-5535965875852701686.post-73661694643973403482009-12-10T22:13:00.000-08:002009-12-10T22:21:02.407-08:00Welcome. Enjoy my musing on how the journey to improve the delivery of rehabilitation medicine in Alberta.<br /><br />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.<br /><br />I'll provide a forum for discussion and feedback. I hope to create a voice for PT that isn't always being heard.<br /><br />My views are my own. They don't reflect the views of my employer (and, at times, may be critical of them).<br /><br />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.<br /><br />This blog is also a forum for my own business consulting efforts.<br /><br />Sincerely,<br /><br />PTWThe Physio Wonkhttp://www.blogger.com/profile/06454058846065019287noreply@blogger.com0