I 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.
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".
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.
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.
Wednesday, August 18, 2010
Wednesday, July 7, 2010
Scaling Up
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. 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.
Since there is no room in the budget for a million dollar investment in new staff, the inevitable questions arise. Is there any other way to achieve this outcome? Is there any other way to convince the senior leadership and finance department? Are there any ways to minimize associated risks? Because of the improved capacity, the new positions could be funded by bed closures and the improved capacity would more than offset the reduced capacity associated with the closures.
Eventually, as I listed the numerous ways to move forward on the proposal, one option that received some acceptance was to implement the changes in just one program area, thereby scaling the proposal down significantly, but all along I expressed that this is not the direction I would take the proposal. I am quite confident that in a showdown, the vast majority of the proposal would be approved as anything otherwise would be confound logic to an extreme. Most importantly, I explained, the solution would not be found in scaling the proposal down. This was received with a certain degree of bewilderment.
“What possibility could be wrong with starting on a small scale?” I was asked. My answer: “You still have the same problems inherent in the current decision if you try to scale back up.” In other words, the decision to allocate a million dollars would be just as hard to make after a successful small scale implementation… which everyone seems to agree would be the end result… as it would be for executive management to make now. So why not ask executive management to make the decision now?
What this experience to me reinforced is that despite other’s perspectives of the big picture, certain mindsets are hard to change. Currently there is a mindset that any request for more funding in a time of financial constraint would be politically incorrect. In my mind, I would rather trust the executive management to see the big picture and (hopefully) make the right decision.
Monday, May 31, 2010
Caseload Guidelines
Sorry for the length... the following is a portion of a draft paper on caseload guidelines and workload management. ...............
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.
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.
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.
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.
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.
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.
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.
What is needed is not another set of caseload guidelines that cannot be implemented due to lack of resources or funding.
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.
The Physio Wonk
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.
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.
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.
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.
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.
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.
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.
What is needed is not another set of caseload guidelines that cannot be implemented due to lack of resources or funding.
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.
The Physio Wonk
Wednesday, May 26, 2010
Supporting CPD
Whose 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?
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.
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.
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.
The Physio Wonk
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.
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.
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.
The Physio Wonk
Thursday, May 6, 2010
Non-Patient Activity
My 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.
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.
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.
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.
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.
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.
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.
PT Wonk
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.
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.
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.
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.
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.
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.
PT Wonk
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
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.
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.
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