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

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