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Raising the Bar in Rehab

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.

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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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Conquer the Fear

Before you step up to the podium, try these relaxation exercises.

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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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Ergonomic Emphasis

PTs can play a prominent role in educating patients on proper ergonomics at work and home.

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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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Innovations in Practice

Electronic tools can help managers prepare for what's coming.

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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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Gaining Mobility in the ICU

How one multidisciplinary team initiated an activity protocol to decrease ICU lengths of stay.

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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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Drowning in Documentation Requirements?

Modern systems can ease the confusion and minimize denied claims.

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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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Coping With Therapy Caps

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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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Bright Ideas

A look at physical therapists who've followed their dreams to entrepreneurial success.

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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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A Move to the Cloud

This transition means instant access anywhere to information you need.

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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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Continuous Improvement
by Lisa Mueller

Over the past several months, my role as rehab supervisor (overseeing a department of 25 people) has offered me a multitude of opportunities to become involved with other areas of our organization's business. I've been able to participate in our accreditation efforts as well as our quality committees and providing support to new clinic implementations. I love the diversity of my job and being able to see how each part connects to provide the most value to our patients. These recent experiences led to me applying, interviewing and accepting a new position -- continuous improvement leader!

There are often bursts of time where my fellow ADVANCE bloggers will write about their contemplation of careers outside the realm of traditional physical therapy, and my own journey is a great example of how skills as physical therapists can easily be applied to other roles. The purpose of continuous improvement (often referred to as "lean" or "six sigma") is to solve problems and remove barriers to provide the most value to all customers, both internal and external. In the healthcare industry, Wisconsin-based ThedaCare is a leader in establishing sustainable management systems built to drive quality and reduce waste. This type of work involves utilizing and teaching others the scientific method of root-cause methodology to identify the basis of problems, implement a solution, reassess and adjust.

Compare each of those points to the role of a physical therapist. Do we solve problems? Yes, every day. Do we remove barriers to provide the best value to our patients, colleagues, and payers? Absolutely. Do we drive quality and reduce waste? Yes! This is one area of physical therapy I'm most proud of -- our dedication to outcome measures and efficient lengths of stay. Do we use a scientific method for root cause analysis? Of course, in every evaluation we identify the etiology of our patient's deficits.

Every talent I've practiced in my career as a physical therapist -- assessing a patient's problems, educating patients, adjusting plans of care etc. are now being carried over into the same mindset on a larger scale. Continuous improvement means making all areas of the business work better and daily assessment of areas needing attention.

This career decision didn't come easily. I had to consider a lot of factors, the most important one being my time away from patient care. In my new role I'll have opportunities to work as a physical therapist, but not on a regular basis. I also thought a lot about this blog -- which I will continue to write but with a new spin on some of my topics. All in all, I'm very excited for this opportunity, and challenge you too to start thinking about the skills you have as a physical therapist and consider other careers to which those skills apply.

What do you think? Have you ever thought about a job outside of physical therapy? What stops you from making a change?

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Let's Talk About Problems
by Lisa Mueller

In my role as rehab supervisor, I frequently prepare small presentations to share with others. Sometimes the leaders of my healthcare organization request updates or other times our sales team needs more information on physical rehabilitation to be able to better sell our service to clients.

There are situations when I will spend time working with IT, for example, to better understand their type of work and processes, so they can in turn help the rehab department in terms of software or other systems support. In each of these situations, my tendency is typically to focus on the victories of rehab. Yes! We can do that! We accomplished this! We exceeded our goals! I get so excited about the progress our department makes and the end result of the patient experience that my focus doesn't instinctively shift to anything else.

I recently heard a speaker give a contrast between GM and Toyota. He explained that the focuses of each company's executive reports took a drastically different approach -- GM on their accomplishments and Toyota on all of the problems with the hybrid model. The following year, GM filed for bankruptcy while Toyota watched the sales of their Hybrid model continue to grow. The lesson? We need to talk about problems. Problem-solving in groups and collaborating on solutions is the best way to drive progress, better outcomes and an improved customer experience.

I think it's important to point out that identifying problems and giving attention to their causes is different than placing blame. Likewise, it's equally important to appropriately recognize the good work done by a person or team.

Physical therapists are built to solve problems. What's the cause of your pain? Why is your strength impaired? How can we improve your gait pattern? We dig deep into the anatomy and physiology of our patients to find the root cause and help implement a solution with an effective plan of care. Many times, we probably don't even realize how ingrained problem-solving is in our profession because it's such a critical and subconscious part of our work. But do we carry the same attention to solving problems for our department, our organization, or our profession of physical therapy?

How far do you carry problem-solving into your world? Is problem-focus part of the culture of your department? Do you believe an emphasis on identifying problems and teamwork to find solutions, instead of accomplishments and accolades, is effective in the healthcare world?

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Details, Details

Using better documentation to sidestep claim denials.

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Outcome Measures
by Lisa Mueller

I am (again) starting to work out more regularly. I'm not sure if it was the long and miserable winter, but I hadn't felt like exercising for a while. Now that the sun is out and the days seem longer, I'm making a commitment to exercising four days a week. I tend to go to extremes, either living a completely lethargic and sedentary life or exercising to the point of not being able to move. I was inspired by a Twitter trend to focus on 30 minutes of exercise and I'm hoping that will force me to moderate between the extremes to a successful regime.

Anyway, I was a little sore after one of my first lifting workouts this season and noticed a few aches in my upper back. Huh. My mind then started to think from the perspective of a patient. How bad was the ache? Maybe a 1 on a 10-point pain scale. Very tolerable. Then I thought about outcome measures -- so I went online to complete the Oswestry questionnaire and was surprised my results indicated a higher level of disability than I would have guessed. Either way, after my light jog the following day, my backaches were completely gone.

I like using outcome measures with my patients -- the information in the questionnaires facilitates good conversation to understand their perspective and goals. Luckily, our electronic documentation system allows for calculation and tracking of outcome measures within the patient's record as well, so it's easy to compare results over time. I have a chart at my desk for reference of the statistical significance for change. In speaking with other therapists, it seems like our profession does very well at using outcome measures with individual patients, but we lack a general knowledge of data and results, diagnosis-specific or otherwise.

One question I have for you about outcome measures is this -- how do you compare the outcome measure results of your patients to other therapists? How do you benchmark against external data? If you have a patient following a lumbar fusion, how does that person's Oswestry results compare to the national average? Do you think it's useful to know an individual patient's outcome measure results and improvements without knowing the standards of the industry?

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How Can We Improve?
by Lisa Mueller

When I think about making improvements within physical therapy, my mind automatically transitions to evidence-based practice and focusing on outcome measurements. When thinking about department goals and making improvements, I consider factors impacting those two areas such as improving access to research sources or compliance when using outcome measures. Since the role of physical therapists lies primarily in helping patients improve, I often forget about other components that could significantly help a department of physical therapists.

At one of my clinical rotations when I was in school to become a physical therapist, I worked at an outpatient facility that provided whirlpool treatments to patients needing wound care. I remember one patient scraping his leg on the side of the whirlpool, which resulted in some bleeding and my instructor needing to file a report describing the situation. The report was extremely difficult to fill out; it was handwritten with lots of boxes to add information and took me and my instructor nearly 30 minutes to complete. A few weeks later, we received an email from the department manager that the report had been made into a digital version (PDF) that could be completed on a computer and printed for circulation.

I remember working in a therapy department that would have a few students rotate through each year. We always set aside a few small projects for the students to assist with, such as researching new equipment or literature supporting treatment techniques. One summer we ended up working with two more students than we originally planned for, and as a result we were able to make much more progress toward our department goals. Our students helped us organize some areas of our equipment closets.

In both situations, I witnessed how seemingly little changes easily improved the day-to-day tasks of the physical therapists. Reports were easier to complete and equipment easier to find. Improving the small things can really add up to staff being happy about their jobs, and I hope to keep these things in mind throughout the year -- celebrating the "small wins."

What do you think? What small things have made your job easier?

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Sharing Information
by Lisa Mueller

When I was a student in my clinical rotations for physical therapy, I spent a lot of time researching various topics. It would start with a diagnosis I was unfamiliar with, which would lead to some research articles where I would learn about different tests and measures and treatment concepts. It was exciting to learn all these new things and implement them immediately into practice, and I would often share these "discoveries" with my clinical instructor.

Looking back on that experience from my perspective now as a rehab supervisor, I wish the student Lisa would have shared more of that knowledge with a wider audience. I wish I would have offered my research findings to other therapists in the department. I'm always impressed with the wealth of collective knowledge our rehab department holds -- with so many therapists each with different experiences and specialties, we have a lot of information when united as a group. So, how do we make sharing information and knowledge easier?

When looking at making departments more efficient, or when implementing the "lean" concepts to healthcare, underutilized knowledge and talent is one of the eight wastes frequently needing attention. Wow! What an awesome thing to contemplate. Using everyone's skills and talents to the fullest capacity is on the same thought chain as working efficiently. That's awesome! This also reminds me of a book I read in physical therapy school and have written about before -- Now, Discover Your Strengths. Recognizing strengths and talents is the first step in being able to utilize them to the fullest potential.

How does your department or facility work to share information and capitalize on each therapist's strengths? Is your work biased toward independent caseloads, and therefore less interaction between therapists? Or, do your therapists connect regularly to share ideas and specific patient cases? With the growth of technology and options like email and web discussion boards, what's the best way to stay connected with each other?

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Three Critical Questions

Before expanding into a new location, grow your practice from the inside.

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