Thursday, October 31, 2013

Another Disney Post: Learning Retail Smarts

On a recent Physiospot Voices post: Business Opportunities: Services versus Products, I mentioned the need for physical therapists to move into the business of researching, developing, marketing, and selling products. This post is a partial follow up to that post filled with gleaned wisdom from my most recent visit to Disneyland.

Oh! If you're interested in my previous Disney posts, look no further!

Learning Retail Smarts from Disney
I've always been a big believer that if you are to learn anything, learn it from the best. Disney is perhaps one of the best companies out there when it comes to customer service and retailing. Specifically, Disney excels at turning the retail experience into one of welcome entertainment and gleeful spending. Their secret: set your products up for success! It sounds so simple... so easy... so matter of fact / common sense. And, yet - why is it so difficult for just about any other retail enterprise?

Well, after another trip to Disneyland, I decided to pay careful attention to the specific retail practices which Disneyland employs. Additionally, I made note of what commonalities every retail location had in common. This is what I found out:

Disney retail is always linked to the Disney brand
It didn't matter which store you were in: the Buzz Lightyear store, any store on Main Street, the Bippity Boppity Boutique, even the "Sword Store" next to Peter Pan, in close vicinity to the "Sword in the Stone" attraction - ALL Disney retail locations served to link it's content, design, culture, and service experience to the Disney brand. One of the strongest examples of this is the Star Trader at the exit of Star Tours.

A most popular collectible, now on its third series, is the Disney Star Wars Vinylmations. Blending the figure of Mickey Mouse with the visual design of popular Star War characters, Disney has been effectively linking Disney & Star Wars far before Lucas sold the rights to the Walt Disney Company.

Such products serve to not only strengthen the specific themes of each attraction or area of Disneyland, it also reinforces and EXPANDS the brand at large - seriously increasing market share. This is an area for which some physical therapists seem to struggle; there seems to be a sense of disdain to be associated with another setting of practice - as if "those" PT's shouldn't be related to "you". There's this climate of fear; fear of being blended into generalities. However, the broad generality is what comprises the strength of Disney: Star Wars, Avengers, Pirates, Donald Duck, Mickey Mouse, the train station, Toy Story... they are ALL Disney. Unity will always be more powerful.

Disney + Star Wars Blend

Star Wars Potato Head 

Classic Mickey Mouse Hat blended with R2D2 (even the ears are formed in the geometrics of the Death Star!!!)

Even Star Wars Angry Birds! Talk about brand expansion and explosively penetrating ranges of market shares.

Disney retail is themed by the attraction
Alluded to in the point above, each store at the end of each attraction is specifically themed to reinforce the attractions importance. At the end of Pirates of the Caribbean, there is a large store where you can buy pirate toys. Across the exit of the Indiana Jones Adventure is a large store full of paraphernalia for which you'd expect an adventurer to wield. After exiting the Haunted Mansion or Tower of Terror, similar content is seen in the stores of which you exit into. This brings us to the next point.

Collectible Wall of Fame

Death Star Architecture!

Disney retail is typically part of the attraction exit
When you are emotionally pumped up on the experience you just had, the store is there, offering you the opportunity to spend money on souvenirs, collectibles, clothing, and the like to memorialize how much you liked that particular experience. Not only are you on a high from the ride, you are now exiting into another sort of high where you can take a piece of the experience home with you. While I cannot clearly recall what Paco Underhill, author of "Why We Buy: The Science of Shopping", says on this type of architecture, I can confidently surmise that research would demonstrate higher percentage of purchase conversions to stores attached to the exit of an attraction vs. stores which are merely adjacent or across the street. Applications to business practice??? MANY!

As you exit the ride via these bay doors...

You arrive at this ramp to exit into the Star Trader store...

You see amazing photos of Star Wars content on the way...

You walk down this ramp, and...

See the exit... And! Oh, what's that? TOYS?!

Disney retail experience is part of the attraction's experience
All Disney stores, restaurants, etc. have cast members who help accentuate the thematic experience of each attraction, world, or area. Additionally, the presence of such cast members indeed perpetuate the experience if the ride, attraction, and/or show. The Star Trader cast members are dressed like they are right out of a sci-fi film. The cast members at the Golden Horseshoe look like they are out of the 'ol West. This goes for every possible nook and cranny of Disneyland. And, it is significant because this adds something very valuable for which most retail operations forget - THE EXPERIENCE. If people have a positive experience at a retail location, they are more likely to stay in a store longer and buy more things.

Be honest now... you're thinking about how you can climb into that X-Wing cockpit, aren't you?

Disney Retail is Done with a Service Experience
Instead of the hard driving bargains or intrusive interest in your retail behaviors, Disney retail is done in a welcoming environment where shoppers aren't crowded out and intimidated by the cast members. This is executed via body posturing, the mellowed intensity of eye contact, the vocal projections which invoke a sense of calm... all elements which make you feel very at home and unpressured to buy.

When a choice is made, Disney cast members always ask if you found everything you were looking for, or, if there was anything else they could do for you. Pride is taken in their work; gift wraps, boxes, and bags are put together with care and precision. Upon payment and exit from the store, the cast members continue to give this service experience by continuing the "on stage." For example, when leaving the Star Trader, it's common to hear cast members say (as much in the previous point above) "Thank you! And, may the force be with you!"

Beauty and the Biz: A Quick Tangential Anecdote
The retail experience is flashy, emotional, in the moment, and based primarily on perception. If you'll indulge me in a slightly tangential anecdote: a few months ago, Japanese visitors toured the facility where I serve as the Rehab Director to learn about the senior living and skilled nursing/rehab business. This business pattern is quickly rising in demand in Japan - and - it is a business that has yet to be full established in that country.

During their tour of my department, they spent a significant and disproportionately long amount of time asking questions regarding physical modalities in rehab services. I tried to give spiels about manual therapy, therapeutic exercise, neuromuscular re-education, and the educational level of my therapists - just to see if they'd bite - nada. In fact, the interpreter kept telling me there were more and more questions/curiosities on the "healing technologies" of physical modalities.

Lesson: Things that are attractive are valuable. Additionally, technology means relevance. Regardless of what anyone thinks of the clinical significance thereof, anything that has lights, gismos, gadgets, screens, sound, switches, touch pads, etc. - all these elements are perceived as cutting edge, valuable, and worthy. If it is beautiful, then it has business potential - it's up to you to make it a worthy business to pursue. Think about it... ;)

Retail Truth: To Sell, Is To Solve
In retail, if you've sold a product, then you've solved a problem. A customer may need a gift for a friend, a tool for home improvement, a cleaning product, food, a toy, a movie, a book, or perhaps a hair product - by making the trade, the retail establishment has satisfied the need of their patron through the physical transference of the product.

Most healthcare professionals are not comfortable with sales and retailing. As we all know too well, sales goes against many deep running, cultural fibers in our professional identity. Sell up, ourselves? How dare we? Our skills, knowledge, and outcomes should speak for our value. Right? WRONG! Couldn't be more wrong, in fact. In my opinion, when the purchase moment arrives, very few buyers care about the details behind their choices. Recommendations, first impressions, reviews, and presence of the sales experience comprise much of the winning ticket.

For myself: when people arrive at The Remington Club and meet me as the Rehab Director, I tell them about how much "therapy" their family members will receive. I tell them how experienced my rehab therapists are, and, that I am quite involved in the overall care as the director. I say all this in a warm tone with a quiet understanding so that the touring family can fully absorb what they are about to commit their family members to. I express that I, personally, add as much value to patient care as I can; offer the expertise of my doctoral education to the highest benefit of all of our residents. I share that the nursing/residence ratio is much above the par of competitors. The food here is gourmet quality; my first meal at this facility was beef tips with red wine sauce! I expound that the Remington Club is the highest-end senior care facility in the region; it is very expensive and extremely exclusive - fortunately, your family member has a medical need which will be covered by insurance... their care will be a 5-star experience.

You will all be in great, very caring hands.

Sold and sold!

Closing Thoughts
So! What changes will you make to integrate Disney retail smarts? Will you involve new training to your staff to include a service experience to your retail operations? How will you solve the needs of your patrons? 

Tuesday, October 8, 2013

Management Tips: #AcutePT

Alright!!! This post has been a LONG time coming - I've waiting so very long in the gathering of my thoughts to bring these #AcutePT management concepts together. I'm very excited to share and discuss this very exciting, dynamic, challenging, and often "controversial" pattern of physical therapy practice.

Management Tips: #AcutePT

Sucks... It's still a business
One would figure that the hospital environment could and/or should be the one place where science and clinical common sense would reign supreme. In a practice setting where peoples lives are at stake on a second by second basis, shouldn't such values outweigh the bottom line? Unfortunately, they do not. Most Acute PT departments are budgeted through an internal capitated fund; department A gets X amount of dollars no matter how much work they do or do not do. This, of course, leads to the discussion of PRODUCTIVITY!

Keeping Productive
The most generous productivity standards I've seen are held at or above 75%. Unfortunately, most departments measure this level of productivity as units billed per total hours worked. What this allows for employees to do is to spend generous amounts of time (as if one was working with RUG levels in the skilled nursing setting) with less numbers of patients when rmore patients could have been seen in the same amount of time. The reality is that staff members who spend 45-60 minutes with patients who could very easily be completed in 15-20 minutes seem more productive than PT's who are blazing around the hospital, picking up 2 or 3 evaluations per day while only pulling 70% "productivity"... Yeah. There needs to be a better way.

Acute PT is a Supply Chain Problem
Honestly, the best way to operationally view Acute PT is to see it as a business problem requiring a solution. In the end, Acute PT is an ongoing supply chain management task. There are X amount of patients required to be seen on a daily basis. Y amount of patients get referred for consults a day in which most physicians (and nurses) "expect" evaluations to be completed the moment the order set has been confirmed in the computer. Sound familiar? Oh yes, and patients should all be BID if not TID - and - the difficult ones that never seem to want to leave the hospital should be seen 4 or 5 times a day! Right...

Solving the productivity problem will naturally solve the supply chain difficulties. The inherent problem with most productivity standards in Acute PT is that there is no natural system for accountability. As a PT, I could easily see 6 patients for 1 hr treatments in an 8 hour day... taking my sweet time to get my minimal requirements of 75% productivity. While some programs have allowed for PT's to have a booster unit in their productivity calculations for evaluations (ie. 1 extra unit calculated into the 4 unit, 1 hour patient encounter), this typically leads many of the PT's to cultivate an even lazier approach.

"Now that I get FIVE units for one hour evaluations, AND, I only need to get 24 units a day - well then, I only need to see 5 patients instead of six!"

Sound familiar? Yeah. No wonder there are so many dysfunctional Acute PT departments. My suggestion is this: make your staff become stakeholders in their work. Much like many emerging outpatient programs are now giving a lowered base salary combined with a percentage of billed services as a bonus, Acute PT programs need to start thinking in this manner. For the outpatient clinic, if a PT is only 50% productive, the amount of billed services will be lower and their overall pay will reflect this. The unproductive employee will hurt from this behavior; the facility does not hurt as bad. So what's the Acute PT version?

I suggest that a dual productivity scale is necessary in a capitated environment. PT staff should be held to a minimal standard of X amount of billable units a day - AND - be held accountable for the NUMBER of patients seen per day, rewarded if they exceed the average. Why is this? Because it goes back to the supply chain management problem.

Most Acute PT programs are limited in their funds. Managers are only allowed to hire so many rehab staff because they are only given a certain amount of dollars to work with no matter what the census needs are. When complaints occur, it is typically because patients are not seen on a certain day (ie. a weekend day), because an evaluation wasn't completed in 12-24 hours, or, because "special" patients haven't been seen BID or TID. The problem really is a service response, not a clinical one.

If staff is held to the understanding that their contribution of value is the number of services rendered per day vs. the number of units billed for, staff that have made habits of "occupational comfort" will naturally performance themselves up - or out.

I'm also a big believer in rewarding outstanding staff performance. Those who pick up extra evaluations, treatments, or are engaging with nursing staff (an element which is absolutely critical in Acute PT) should be rewarded as such in monetary form (bonus or raise) or via fringe benefits. Oh, the flip side is true; you're a manager, after all - don't be afraid to terminate employees that simply don't make the cut. One weak link will destroy the entire infrastructure you've worked so hard to strengthen.

However, even with solving this productivity-supply-chain issue with a dual accountability scale, the problem isn't completely solved. Supply chain means that when demand is made, supply MUST be delivered and done so quickly. Solution? Expand your service window by working longer hours.

Working Longer Hours
The most successful Acute PT programs I've seen have a mixture of 8 hour and 10 hour per day employees. This allows for late surgery patients to be see on post-op day zero, and, for "STAT" discharge evaluations to be attended to - you know the ones, those "get them out the door" cases that all curiously get "ordered" at 4:30 pm. These longer hours are also highly attractive to the younger generation of employees who relish the opportunity to work four, ten hours days. However, to truly make this successful, staff will inevitably need to rotate in and out of weekend schedules. Also, this is where the dual accountability scale for productivity is so important. Ten hour days in the acute care setting is a great way to physically burn out and begin the process of disengaging, and, getting slack or even lazy. This requires management to keep keen eye on employee engagement (to be discussed later in this post).

Prudent Use of Physical Therapist Assistants
It's odd that lately, only the PT progression has culturally undervalued its support staff. In medicine, physician assistants and nurse practitioners have only become all the more valuable and in demand due to their cost saving skill sets. And, let's be honest - does it REALLY require a DPT to gait train the average, run-in-the-mill patient with pneumonia on the medical floor (with no other significant conditions)? Now the ICU, orthopedic floor, spine floor, cardiac floor, oncology, neuro unit, short stay/observations, emergency department - those are certainly different issues.

Again, Acute PT is still a business, and, the business is supply chain management with a fixed amount of profitable funds. The only way to keep black on the financial ledger is to cut costs. This is where PT Assistants come in. High level, functioning patient populations, uncomplicated orthopedics and other elective surgeries, as well as the generally stable medical patients - these are great candidates to increase utilization of the PTA labor force.

In my humble opinion, the most efficient use of PTAs (at least under California law) is to utilize them by the hour, two at a time, under the supervision of a salaried PT. The best case scenario would lend such that several management tiers of PT's exist in the framework of an Acute PT department. Some hospitals may call this a zoning model.

This would require a supervisor/manager to administrate several lead PT's on salary, a handful of per diem/hourly PT's, and an army of hourly PTA's. Lead PT's would be responsible for managing the PTA's labor and clinical interventions as well administrating evaluations and case managing (hint hint) for their respective units/floors. Per diem PT's would serve as labor overflow for evaluations and treatments.

Why this structure? It runs, once again, back to the issue of supply chain management. The bottom line for most hospital PT departments are most related to discharge and patient safety in house. Business is business; this is a point that NEEDS to be understood for departmental success.

The Future of Acute Care PT Practice - Case Management & Value Development
The bottom line for hospitals for physical therapy departments are these: (1) when can the patient discharge? And, (2) to where (and with what equipment) can they be discharged to? Number (3) is a very difficult to measure value-added presence for fall prevention/safety and a global culture of mobility/health improvement for both patients and staff.

I mean, let's be honest here: how fed up is just about EVERY Acute PT department and their nurse-case manager/social worker compadres by which communication is constantly bounced back and forth between patient, nurse, physician, physical therapist, and case manager/social worker? The best solution is to cut out redundant loops of communication.We all know this: the more people that play the telephone game, the more inaccurate the end message becomes.

The best option is to have the lead physical therapists work along side of (if not as part of) the case management department. Each unit/floor should have a physical therapist, a nurse-case-manager, and a social worker to comprise the discharge planning team. Imagine all the PTA management challenges which would be so easily conquered if a salaried PT were to also act as a designated case manager for a unit/floor/zone, say 25-50% of the time on each unit/floor? Food for thought.

The other future aspect of acute PT practice is value development. Being a very present and active part of physician interaction and nursing practice is the key to a dynamic and valuable PT program. Helping develop a nursing mobility program where nurses are encouraged to screen mobility, develop their own mobility plans, fall prevention programs along side of PT assessments, etc. - these are the future marks of a cutting edge acute PT program. Oh! P.S. - in a hospital, nurses run the show - make the nurses happy, and they will make you happy.

What would really push an Acute PT program into warp drive would be long term outcome trackings for population groupings, diagnosis groups, and treatment segmentation in measurements of bio-markers, overall health recovery, and other non-functional (but critical physiological markers) along with readmission rates/causation and length of stay projection/prediction/adherence. Again, this drives physical therapy practice in the direction of feed-forward case management.

Let's Not Forget The Clinical!
With all this talk about business management, let us not forget about the clinical side of life. After all, physical therapist are clinicians at the practitioner level providing a service in this setting. In the more challenging areas of ICU, neuro, emergency department, etc. - clinical savvy and interpersonal schmoozing is a must! If an employee isn't getting along with patients, family members, nurses, physicians, and other support staff - forget it... You've got a dud in place; reassign that person to another unit/floor. In the same vein, if you have an employee strapping on the gait belt and doing nothing but transfers on the neuro floor... *insert buzzer sound here*.

This all sounds so sad, doesn't it? But why? Well the answer is employee engagement. Acute PT is a setting which is quite easy to burn out of. The patients can be difficult, clinically challenging, and uncooperative. The interdisciplinary climate can be frustrating, interest competing - new ideas mix about as well as oil does with water.

With lack of employee engagement, much of the problems seen such as developing lazy ways to make minimal productivity standards and "seeing" patients for mere transfers/chair exercises becomes increasingly common. With such drab levels of clinical practice, nursing staff will quickly view physical therapists as glorified human walkers and people movers. I can guarantee that if you're hospital nursing staff has even a hint of this view of your department, you have some weak links that need tightening - I bet you already know who they are. If you don't, you better find out quick!

Employee Engagement
Since we mentioned employee engagement, let's flush it out. The biggest threat of employees at risk for burn out, complacency, or resignation is lack of purpose and passion in the workplace. Meaninglessly walking patients down the hall way, performing nothing but Max x2 transfers... these situations put at serious risk, the existential value of what people do for work.

Additionally, physical therapists are PROBLEM SOLVERS. This is the inherent nature of our practice and needs to be fueled for continued passion. When jobs become mechanical, they become boring. What physical therapists need to be considered for is hospital administration and leadership.

Managers need to quickly identity acumen, talent, and influential individuals within their departments. The hospital climate is all about operational philosophy and social power. Popularity is key. The sad thing is, the more popular a physical therapist is with other departments, the more commonly this PT will be the target of intra-departmental angst and jealousy. Management must squash this sentiment and associated behavior as well as protect the talent. When word gets out that one of the PT staff members shines out extra bright, snatch them up and put them in a position of leadership BEFORE their threatened co-workers get the better of them.

Additionally, individuals who wish to rise up above the "director of rehab" level of administration MUST pursue an additional degree. I've mentioned this many times on posts and tweets - health systems consider nurses and physicians the natural choice for leadership at the executive level. Despite physical therapists being educated at a DOCTORATE level, they do not fit the conceptual mold of officer level leadership in healthcare. An additional degree such as an MBA, MPH, or MHA is a requirement to break the mold.

It is also most helpful if a physical therapist demonstrates exceptional performance in driving the marketability of the hospital itself. So often, rehab stories are the stories that marketing departments melt over. A stroke patient who is learning to walk, a trauma patient who stands for the first time with teary eyed family members at bed side. THESE stories are the stories that sell - and - anything that sells, by definition, demonstrates value. The individuals involved with such stories should also be quickly groomed for leadership opportunities. Again, the hospital environment is all about politics. If you are known, that much more power is behind your name. If you are liked, that's even better. Make sure you highlight your employees! And, once again, make sure you protect them for collegial jealousies.

Keep your employees engaged, interested, and passionate about what they do and who they are! We must break the mold and set expectations of the hospital culture. Acute PT's need to be more than "eval machines" and PTA's need to be more than commando treatment gurus. The entire concept of Acute PT need to be re-imagined and revolutionarily administrated. To do this, it requires much grit, thick-skin, and business savvy. To do this, management needs to be supportive all the way up and down the chain of command. Sadly, for many administrations, one must get up there first before the support can be given. Once given, highlight and grow those with talent, demonstrating acumen & performance - be sure to develop the new ideas and the new solutions - these are the sparks that will continue the flames of passionate workplace engagement.

Closing Thoughts
The acute care physical therapy practice will play a very intriguing and important role in the coming days of the healthcare industry. With payer source in question, length of stays to be decreased further, and more work to be done with less funds - the expertise and acumen of physical therapists can certainly be the booster charge hospitals need to reach their true potential of decrease the overall cost of healthcare. Perhaps more importantly, physical therapists in this environment will be best positions to make positive, long term impact on the future life choices of individuals in a health system.

The barriers to this include a stagnant, if not fearful culture to change within PT departments ranks. Lack of physical therapy leaders in the hospital environment who are savvy with business, nursing/physician politics, and stakeholder dynamics for which is the beating heart of almost every hospital based "issue."

As always, to make change, it is easiest to do it in-house rather than to gun for things out-house. Fix those productivity and operational factors first. When the department is up to snuff, then options will open. Many businesses and administrations work with the philosophy of "It pays to be a winner." The more a program is successful, the more funds, technology, support, and toys they get. Once this level of performance is reached, THEN the iron will be hot to strike for grander improvements to the hospital operation at large.

I hope you've enjoyed these management tips for acute care physical therapy practice. There is certainly much to be discussed and flushed out. By no means are these the only tips out there, however, I do find that these tips are quite useful to the majority of acute care PT programs. I hope you will find them helpful in your pursuit of best practice.

Warm Regards,
-Ben Fung