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Raising the Bar in Rehab

PT Payday
by Lisa Mueller

When I was in high school, I worked at a local camera and photo studio -- it was a really fun job. I learned how to develop film and pick out mats for framing. It was probably where I developed my organizational skills, by following the rules of the shop to keep all the film negatives in order and prepared for customers to pick up. The business was family-owned and eventually closed while I was in college, largely due to the rise of digital photography.

There were two times during that job where my paychecks bounced. The owner explained that their accountant had failed to transfer money over and kindly paid for the bank fees when it occurred. I didn't think anything of it and hoped it didn't mean my kind boss was having any serious financial problems himself.

I haven't ever experienced a failed paycheck since that time, but wonder if (or when) this situation happens to physical therapists and how they handle it. I once interviewed at a small private practice physical therapy clinic where the owner asked if I'd be able to secure my own health insurance with my husband in order to keep her costs down. I was shocked and didn't know how to respond in that setting -- not only to formulate a response to my health insurance benefit needs, but also to eliminate any further discussion about my marital status in an interview.

Owning a business requires taking a lot of risk. I'm sure there are owners of physical therapy practices who cut back their personal finances significantly in order to invest in their business. But how many physical therapy clinics live "paycheck-to-paycheck?" Is it possible to investigate the financial stability of a clinic before accepting a job position? As my fellow ADVANCE blogger Allison Young has been writing about her own experience at a closing physical therapy practice, we know PT clinics are not immune to business failure.

What do you think? Have you ever received a bounced check or missed a paycheck from your physical therapy employer? How did you handle it?

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2014 Salary Survey Results

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Healthcare Knowledge Is Power
by Lisa Mueller

I was plugged into the news last week in anticipation of the Apple event where the iPhone 6 and iWatch products were announced. I look forward to learning about new technology and have grown to look forward to the events hosted by Apple (and other tech companies) each year. What excites me about the new Apple line, more than the other enhancements, is the new HealthKit app.

I like things that make living a healthy life easier. I like seeing calorie counts on menus and having any information available so I can make better decisions about my health. I love the concept and practice of transparency in healthcare. How can we expect our patients to make educated decisions about their care if we don't provide them with all the necessary information?

I've heard stories from patients (not to mention my own experience) about receiving bills several weeks or months following a healthcare procedure that were much higher than anticipated. Or stories about gaps in communication between some of the healthcare team members that resulted in components of the patients' healthcare status not considered when determining a treatment plan. Or stories about patients not knowing their lab results because they had missed the multiple calls from their healthcare team.

Products like the HealthKit are solutions toward some of the problems we see in healthcare now. Information is accessible and integrated to empower patients to choose the best healthcare plan for themselves. This makes me happy to be a part of the healthcare profession -- to see improvements that I know will ultimately mean better patient outcomes. The next step (in my opinion)? Tying in health insurance so prices are clear to patients before the time of their visit.

What do you think? What advancements in technology have you seen result in better care for patients? Does your physical therapy clinic integrate functional deficits or special testing results with the patients' complete medical record? How do you contribute to giving patients information about their care options and the costs?

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ADVANCE App Reviews

Learn about which apps can benefit the PT/patient relationhip.

Expired Medications
by Lisa Mueller

I toured an outpatient rehab facility a few years ago and was brought into a room that was used mainly for storage, and sometimes for wound care. There was a smaller whirlpool in the corner and a moderate amount of wound care dressing supplies and handouts for patients regarding wound care pathologies, symptoms and treatments. The tour guide (a therapist at the facility) explained that wound care was an occasional area of patient care, but not regularly. At the time, I was intrigued that physical therapists were involved with wound care and continued on the tour without a second thought about the facility space.

As I was driving home with other colleagues the conversation developed into noticing how many products in the storage room were expired. While I missed the observation, my colleagues reported several bottles of saline had expired along with alcohol hand sanitizer that was also past its expiration due date. It made sense -- the room was not used often, and wound care patients were infrequently seen. I can imagine reviewing products in that area to be overlooked.

I thought back to my own workspace -- how often did I check to make sure the hand sanitizer was within an acceptable date range? Never! Furthermore, it may be difficult to order supplies for a patient population that isn't seen regularly at the clinic. Available supplies may sit on the shelf for an undetermined period of time until they are needed. I can completely understand how this would happen at a physical therapy clinic.

While my colleagues picked up on this gap, I wonder how often patients notice things like this. I'd imagine if I went to a pharmacy and received a bottle of expired medications, I would probably panic! However, how often do physical therapy clinics look for expired supplies in their treatment spaces? Is looking at dexamethasone for its expiration date part of your normal routine? What other products in your clinic carry expiration dates? What do you think?

Reviewing expiration dates of products wasn't a part of my physical therapy education (unless I accidently slept through that part of the syllabus!). I'm always amazed by how much I learn about physical therapy just by observing practices and talking with other therapists.

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Mobilize Mexico

An enterprising PT opened a clinic to address mobility.

Our New Pet
by Lisa Mueller

I brought home a new dog last week -- a beautiful 2-year-old affectionate and sedentary English bulldog named Darcy. After a few years of talking about getting a pet, I decided to look more into some breeders and came across Darcy. We decided she seemed like the right pet for us and the right time in our lives to add both responsibility and joy to our lives.

Within a few days we were visiting with the owners, shopping for dog supplies, and arranging to pick her up for the 1-hour drive home -- quite the whirlwind! So far (day 4), things are going pretty well despite the massive change to our pre-Darcy lives. We're getting used to the dog (specifically, her breathing) and she is getting used to us. We have a pretty good routine of feeding, drinking, bathroom and sleeping.

While this may sound obvious, I'm still surprised by how immediately our lives changed when this dog took its first steps through the door. Last week I didn't think twice about my schedule, but now I'm counting hours on my fingers to figure out when the dog will need to be fed. We usually don't use air conditioning in the summer, but now it's running constantly to keep the temperature acceptable for a dog with inherent respiratory challenges.

My mindset has changed from one of near-selfishness to awareness and planning on behalf of the dog's schedule. It has been a fun few days for my husband and me as we start this chapter of our lives. We're very lucky that the previous owner has answered so many of our questions and given us so much information to be completely prepared for this transition.

I wonder how many patients of physical therapy experience similar mental changes following an injury, whether acute or chronic. Within a very short period of time, we have seen patients experience life-changing injuries. A patient with back pain, for example, may have never thought about a commute to work before an injury, but now finds himself thinking about transferring in and out of the car and tolerating the length of the car ride.

In many of these patient scenarios, physical therapists can provide information, resources and accessibility for when a patient may need support, just as Darcy's previous owner did for us.

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Ice Bucket Challenge
by Lisa Mueller

Over the past few weeks, I've noticed more videos of my friends appearing on various social media networks of themselves dumping ice cold water on their heads and nominating others to do the same. I didn't know much about how the trend started and after some reading (as well as the messages in each video), learned it was a fundraising effort to raise money and awareness for ALS.

Pete Frates, a former college baseball athlete who has been diagnosed with ALS since 2012, helped to start the viral #IceBucketChallenge online. According to the website, "The challenge involves people getting doused with buckets of ice water on video, posting that video to social media, then nominating others to do the same, all in an effort to raise ALS awareness.

People can either accept the challenge or make a donation to an ALS Charity of their choice, or do both." As of August 24, the Ice Bucket Challenge has raised more than $70 million, and the ALSA website has experienced delays due to the overwhelming number of visitors logging on to donate.

I love the Ice Bucket Challenge! I was nominated by my aunt this weekend and was excited to be a part of it. As a physical therapist I've seen a lot of fundraising efforts, most of which are research letters in the mail or walks to support various causes. I like that this epidemic is unique and regards a pathology that typically doesn't receive much fundraising attention.


Having worked with a handful of patients who were diagnosed with ALS, I know there is still much research to be done. As the progressive neurodegenerative disease impacts the nerve cells of the brain and spinal cord, patients typically lose motor function over time, significantly impairing their ability to stand, walk, or care for themselves. Physical therapists can play an important role in helping patients with ALS live independently for as long as possible, usually with the help of caregivers.

Have you seen videos of the Ice Bucket Challenge? Have you been nominated? Will you donate to Have you worked with a patient with ALS? What are your thoughts about this social epidemic?

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ADVANCE ALS Ice Bucket Challenge Video

We accepted the Ice Bucket Challenge -- Take a Look!

Is Ebola Frightening?
by Lisa Mueller

I've been trying to keep up with all the news coverage of the recent Ebola outbreak in West Africa. The story is quite captivating as it is not a subject I often hear a lot about, and I like learning and reviewing different topics related to medicine. Part of what is so interesting about the media's attention to the Ebola outbreak is the impact perspective Ebola has compared to other pathologies.

While important to contain from further outbreak, Ebola has so far impacted a fraction of the population as diseases such as AIDS or lung disorders. While the families, friends, and communities of the Ebola victims likely have a vested interest, why are so many people interested in this topic?

Physical therapy seems to be different in terms of what we publish and provide information about. There is lots of information on low-back pain or balance disorders, which are common in our profession, and less about select pediatric disorders.

Physical therapy was arguably defined as a profession during the polio "outbreak," so it will be interesting if physical therapy media follows future public health outbreaks. Have you been involved with patients who came to physical therapy as the result of a public health outbreak?

One of the items on my bucket list is to participate in a volunteer trip to help with natural disasters. A group of my colleagues were able to travel to Oklahoma City after the tornados (last year or in 2012) and said the experience was very rewarding because they could actually help others.

There are a few websites I've researched that host physical therapy trips to provide services to rural areas or other countries. A lot of planning goes into those trips for laws, regulations, travel arrangements and equipment, but I can imagine that the fulfillment in providing physical therapy to those with limited options is worth the effort.

What do you think? Have you discussed the Ebola news with your coworkers or patients? Do you monitor public health articles or trends?

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Becoming a PT in Haiti

A university on the island opens its doors to the first class of physical therapists.

Public Speaking
by Lisa Mueller

This week, I'll be giving a presentation to half of our company about a recent continuous improvement project I've worked on. We are just weeks away from our project being implemented, and many of my coworkers who haven't been involved in the project don't know what to expect (rightfully so -- their focus is patient care!).

I've been involved in much of the preparations and will be presenting with one of our regional medical directors. Our presentation materials content includes a project overview, how the project will impact our medical clinics, things to prepare in advance and a reminder of some policies and procedures for our organization.

I'm nervous. When I taught a continuing education course regarding physical therapy in intensive care units, I wasn't nervous at all. The difference here is that continuous improvement is somewhat new to me, whereas physical therapy in acute care was something I knew inside and out. I knew the pathologies, treatments and research. This is different -- I don't know the content as well as I do physical therapy.

Part of my preparation this week is to review my continuous improvement training materials, books and articles, as well as my presentation notes to feel more comfortable. To me, knowing the content is very important to being an effective presenter; although I've known several people who have taught me a lot even though they weren't subject matter experts on a topic.

A coworker of mine was kind enough to sit with me for an hour, reviewing notes she took at a public speaking seminar. She reminded me of points like keeping my arms at my side and maintaining eye contact with an audience member for the length of the sentence as I speak. I probably wouldn't have given much thought to these tips, but I know the little things matter as much as the big things to some listeners.

So I bought a new skirt and will attempt to wear high heels for the presentation, which I need to practice wearing in the next day or two. I'm excited for the opportunity to teach my colleagues about this exciting part of our company -- making improvements!

What about you? Have you ever spoken to a large audience? How did you prepare? Do you wish you would have done something differently? Have you received feedback from speaking to your team or department?

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To My Younger Self
by Lisa Mueller

I had the chance to see a lot of my family this weekend at a wedding, which included hearing several of my younger cousins talk about touring and applying for college. At one point, my uncle asked me if I would have chosen a different school in hindsight. I turn 30 next month and am now realizing that I have the years and experience required to provide advice to my younger family members. We discussed the pros and cons of multiple colleges my cousins were considering, but his question sparked a thought -- what would I tell my younger self, if I could? And not just about college, but about physical therapy in general?

I scanned through my old performance reviews as well as some of my older blog posts to remind myself of who I was five years ago. I found this blog about inconsistent schedules and motivation and chuckled as I read my own thoughts. I remember being caught up in the inconsistency of acute-care schedules and wondering how to best motivate my patients. I still contemplate motivating and engagement factors for the people I'm working with. I smiled at seeing "You have to expect the unexpected" written at the end -- I had the wisdom to know that fact but I'm not sure I fully understood it then, or even now.

I think if I could tell myself something, it would be to not worry as much and to recognize that even the most detailed plans are often not in your own control. Patient schedules, continuing education classes, residencies and career opportunities may not always happen as you expect or hope they might, and that's okay. I would tell myself that the people you surround yourself -- patients, colleagues, or personal -- are critical to helping you solve problems, develop yourself and make the day memorable. Finally, I'd tell myself to stop comparing myself to a standard or idea of how things should be. It is okay, and encouraged, to take risks and enjoy the road less traveled.

What about you? What would you tell your younger self, if you could?

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Working from Home
by Lisa Mueller

I went on a tour of a physical therapy facility recently. When documentation was discussed, the facility supervisor happily explained their new electronic documentation system and the ability to log in remotely and complete notes from home or any other location. My ears perked up. Documentation anywhere! Oh, the possibilities! But, as I thought about this idea further, I'm not sure the option is truly beneficial.

I notice a significant decline in the quality of my patient documentation, or documentation of meeting notes the longer I wait to write them. I can't remember details as well and it's harder to separate each patient, or each meeting, from the other events of the day if I save my documentation until later. So while the idea of documenting from home is appealing, it's not the best option for me most of the time. There are some days when I'll be interrupted at my desk or just can't concentrate on my computer and being able to take my work elsewhere is helpful, but overall it isn't worth the delay. I've been surprised and impressed by other people (my clinical instructors!) who don't have the same problem as I do and can recall lots of information sometimes days after a patient appointment.

I've met several people throughout the past few years who prioritize working from home as a critical part of their job satisfaction. This isn't usually an option for physical therapists or other professions with hands-on work with patients but brings up the conversation of the working environment possibilities. I'd imagine there are times when working at home will present interruptions as well, although these are probably more related to house chores! I remember studying in my apartment in school and finding myself stepping away to switch laundry over, or put dishes away, or quickly vacuum. I'm sure these same distractions would exist when working at home!

Some questions I'd love to get your input on -- How do you work best? Background noise? Complete silence? In an open gym area or in a private treatment room? Does your facility offer mobile computer-on-wheels, laptops, or stationary desktop computers? Does your employer allow working remotely? If so, does it help you stay on top of your administrative work?

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Continuing Education Courses
by Lisa Mueller

A few years ago, I had the opportunity to teach a continuing education course on early mobility with three other physical therapists. We met for several weeks, reviewing the content along with the training and presentation materials. It took a lot of thought and effort to review every detail of the course to make sure it flowed well and the learning objectives had all been explained thoroughly.

Teaching that course was one of the highlights of my professional career. I loved sharing my enthusiasm and knowing patients would benefit from other therapists learning the skills and tools specific to acute mobilization. The 4-hour course was perfect to not completely overwhelm the course participants or cause any of the presenters to lose their voices! Afterward, several of the participants connected with me on LinkedIn and we were able to continue sharing our experiences and learning from each other.

Shortly after our course was completed, we were sent a message from an out-of-state hospital system asking if our 4-hour course could be expanded to a 16-hour, two-day CE course. Our team discussed the option and decided against it for a number of reasons -- logistically to travel with the needed equipment to another state, the time to develop the content to four times the original, and balancing that with our regular full-time jobs. Although we didn't say it out loud, I know I also thought that being responsible for a full weekend CE course was a little too outside my professional comfort level -- I was a PT, not a course instructor! Four hours were much easier to commit.

Looking back, I wish I would have said yes to that weekend course. I wish I had pushed myself to at least try. Even as I write this, the barriers we debated about the logistics and work don't seem to be the daunting challenges they were at the time. It would have been an awesome experience.

There are many times physical therapists have to consider making professional changes. We change employers, or change facilities or settings, or change the type of work we are doing. Only we know what is best for our own careers. What about you? Do you have any professional regrets? At what point in your career have you said, "I should have" or "I wish I would have?"

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Delayed ICD-10
by Lisa Mueller

Medicare and Medicaid announced recently that ICD-10 will go-live on October 1, 2015, which is the third time the change has been delayed since 2009. CMS states that several factors impact the delay of implementing the updated coding guidelines: software, staff training, updating policies and guidelines, as well as paperwork to reflect the changes.

Several of my former classmates were disappointed with news of this recent delay. Their employers provided ICD-10 training along with reference materials for guidance during the transition. Do these delays reward those who cannot meet deadlines? Do those who were prepared for the changes now have to repeat their training and undo their scheduled software updates?

This reminds me of a time when I worked with a patient who had a diagnosis I wasn't familiar with (I can't remember the diagnosis now for the life of me). I ended up doing a lot of reading and research on the topic to be prepared for the patient's next appointment, but was disappointed when the patient cancelled.

I felt like I wasted a lot of my time learning about the disease, and quickly realized that the time wasn't really wasted because I learned a lot that would easily carry over to other patients. Like many areas in my career, this was another example of how knowing more information related to my patients would empower me to be a more skilled and compassionate therapist.

I think the same way about the ICD-10 delays. Those who were prepared will have an advantage to know the changes better than others, and their prep work will only help them through the transition.

What do you think? Are you ready for the change to ICD-10? Have you been involved in training courses yet?

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Limiting Therapy
by Lisa Mueller

A friend of mine recently asked for my opinion about how much therapy she would need following a knee arthroscopy. I talked with her for some time about her symptoms and which PT clinic she was going to work with. She then told me she was worried the physical therapist wouldn't be able to help her within the 20-visit limit of physical therapy her insurance company had for her annual rehab benefit. I reassured her that her physical therapist wouldn't need 20 visits to help her meet her goals, but she was clearly concerned.

I've thought about therapy caps from the perspective of the physical therapist many times, and my thoughts are usually surrounding the paperwork associated with requesting more visits. It can seem like one more barrier getting in the way of direct patient care, and that's what physical therapists love to do. However, what do these limits mean for the patients? Like my friend, does it mean fear that their injuries will continue if they surpass their limit?

While some physical therapists may be frustrated by third-party payers for adding these guidelines to patient benefit plans, I think there's also an underlying opportunity for PTs to demonstrate their effectiveness and efficiency within therapy visit limits. The American Academy of Orthopaedic Surgeons recommends patients find a physical therapist who averages nine visits per patient (there's no detail about whether this number is for surgical, non-surgical, or simply an average of orthopedic PT visits overall).

Is there an area for opportunity here? If a new patient is scheduled for physical therapy with a diagnosis of plantar fasciitis, could you anticipate the patient reaching his goals and continuing independent management after three visits? If so, can we share that information with the patient during his first encounter, to ease any concerns he may have about limits on physical therapy visits?

I've seen what the other end of this spectrum can look like -- patients with no payer limits on physical therapy who may develop an unhealthy dependence on physical therapy. Who, when ready to be discharged independently, report symptom exacerbation and require more physical therapy to manage their symptoms in what seems like an unending cycle.

What do you think? Are therapy caps a barrier to your practice as a physical therapist? Can your practice effectively work well within the guidelines of payer benefits?

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Are Leaders Doers?
by Lisa Mueller

I was talking with a friend of mine about being a supervisor in rehab and about leadership and management of companies. We were comparing the differences between being a physical therapist and supervising a department. I've written about this previously, analyzing some of the traits and characteristics that cross between physical therapy and managers.

My friend said something interesting that I haven't been able to forget -- "People who are promoted are usually good, or the best, at doing things. But being a good leader isn't about doing things. It's about helping other people do things. You have to transition from a ‘doing' mindset to a ‘coaching' mindset, and that's where most leaders fail." Hearing her say this was like an "aha" moment for myself, because I found the words to be very true.

I'm very interested in the idea of hiring people for their strengths and putting them in jobs with tools to make strengths even stronger. In my friend's description, many doers who are promoted to leaders can be evaluated on skills they lack or areas they need to improve. Sometimes, doers have the best role in continuing to do good work.

I think I'm really good at doing things. I keep my work organized and prioritized. I can dissect a project to all of the milestones needed for full success. I visualize the full picture and zoom into details when needed. But, I'm not sure how to measure my success in coaching others, or in enabling others to do their work well. Perhaps this is where engagement surveys are effective to measure the impact leaders have on motivating and engaging their teams.

Do you see a difference between doers and leaders? Where do you see yourself fitting? Are you a doer, a leader, or do you have qualities of both?

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Changing Policies
by Lisa Mueller

When I was in PT school, we didn't discuss organizational policies and procedures very often. Even as a student, my clinical instructor would show me how to do something but I don't recall ever seeing a printed policy or handbook on what to do. Actually, I do remember seeing one master binder that had a ton of documents in it, but it wasn't easy to search for a document in the stack of papers.

Regulations and laws regarding every aspect of healthcare are constantly changing. The billing information needed by a third-party payer may change when benefit plans are reviewed. Changes to how we use rehab equipment may happen when the manufacturer updates the model. We change our treatment approaches with information on the patient's response and new evidence supporting our plans. Things change -- but how do we keep up?

If you are part of a large physical therapy department, or a clinic that has more than one location -- how are changes to your work communicated? How do you find out if a process is updated? Is it the responsibility of the physical therapist to find the information? Leaders to provide announcements and training? What's the best way?

I'm interested in this topic for a couple reasons. First, because physical therapists typically prefer to spend their time with patients, not administrative tasks, so our communication on policies and procedures is most effective when it's efficient. I think staff engagement and job satisfaction is tied to having the information to perform our jobs effectively. Second, I wonder what the impact would be to our patients and their payers if we aren't able to adjust our operations to accommodate changes.

Tell me about your organization -- how do you find policies and procedures you need for your job?

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Connecting Complaints to Satisfaction
by Lisa Mueller
I read an article last year about the top 10 reasons why people make an appointment with their doctor and was surprised to see skin issues as the number-one driver. What an interesting topic to consider; why do we make decisions to see the doctor? Even more, how can we use that information to capture patients at the right time and provide them with the service they need? In this example, plopping a medical clinic in the middle of a busy city with no onsite dermatologist could result in many patients being turned away.  

I did a lot of research last year in an effort to establish an updated questionnaire for patient satisfaction surveys relating to physical therapy. I found questions like, "Did your condition improve as a result of physical therapy?" and "Did your physical therapist communicate with other members of your healthcare team regarding your condition?" Many of the questions I found or developed were about topics such as ease of scheduling appointments, friendliness of staff, and cleanliness of the facility. I was happy with a lot of the content within the patient survey.

At every clinical rotation I had during physical therapy school, I learned something about the patient feedback or complaint process. Each clinical instructor I had taught me about the importance of listening to patients and being a part of any needed solutions to prevent a complaint in the future. Developing these skills to understand active listening, timely follow-up, and even conflict resolution were critical so early in my career. My fellow ADVANCE bloggers have described many situations with dissatisfied patients and families and we are all equipped with the communication tools to help our patients understand our role, their goals and the plan to move forward.

I'm beginning to wonder what the best way is to balance our focus on patient complaints and the drivers for patient satisfaction. A patient may complain about food at a hospital, but later reveal on a satisfaction survey that the quality of food minimally impacted his experience compared to the quality of care, safety and professionalism of the staff. Patient feedback may give us insight into an inefficient process or attention to a facility we weren't aware was broken. Knowledge is power -- how do we take all this information from our patients and turn it into an improved patient experience?

What do you think? How do you field patient complaints at your facility? Do you see themes of common complaints? What is more important to focus on, the things that make patients happy, or the things that make them upset?

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