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?
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?
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?
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?
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?
I took three courses of philosophy during my undergraduate years and never really got into it. I'm not even completely sure I understood the phrase, "the end justifies the means," until I was a little older. Experiences added up and I learned how to focus on the end result to get through the process, and like an "aha" moment, I finally got it.
I'm in the age of family planning. It seems like every week another acquaintance is sending photos of baby bumps and due dates. I remember working with a patient right after graduation who told me, "Don't worry, there's still time for you," when she learned I didn't have kids, and that was five years ago! I had dinner with friends a few months ago who told me that after years of trying, they wouldn't be able to have kids. My friends had other options, such as adoption, but the bottom line was if she wanted to carry her own children, she would (at the direction of her OB) need to try IVF treatment. And there it was -- the ends justifying the means.
I've seen this happen in physical therapy practice occasionally. I educate my patients on their treatment options, collaborate on a plan of care ("the means") and establish together the goals ("the ends"). Some patients decide that the ends justify the means, and others don't. For example, a patient wanting to walk again may decide the hard work of pain with weight bearing, the challenge of balance training, and the difficulty in learning eccentric control is worth the end goal of ambulation. Another patient may see the same process and determine he cannot tolerate the means to achieve the end.
Our role as physical therapists is simple -- help support, educate and guide our patients during the healing process to get to the end. We have the education and experience to see our patients' goals before they're able to visualize their own success, and our jobs require us to remind, reinforce and facilitate our patients as they work through the difficult processes of changing the way their bodies function.
What do you think? Do you have patients who struggle through the process of change, only to be pleasantly surprised by the outcome? Do you have to educate your patients on why the ends justify the means?
One of my student clinical rotations was at a smaller physical therapy outpatient clinic with just three staff members who managed all aspects of the operations. They all worked seamlessly together and the patients had a lot of fun during their appointments, partially because their therapists were very knowledgeable about every aspect of the business. As I think about that facility now, I have even more respect for those therapists than I appreciated when I worked alongside them.
When I interact with patients, my brain is focused on every component of practicing physical therapy. I consider differential diagnosis, muscle fiber length-tension relationships, observing my patient's response to changes in position and palpation... all of the factors that go into successful treatment. It's not easy for me to switch from that kind of thinking, to say, billing cycles or scheduling equipment calibration. The group I worked with in school kept track of all the billing, scheduling, staffing, ordering of supplies, as well as paying the building rent, electrical bills and insurance coverage. This is what a lot of private practice physical therapists take on, and I am impressed.
Many times we are asked to wear additional hats at our jobs. There are other components of physical therapy practice that extend beyond patient care and need to be completed, whether the setting is private practice or a large organization. Each of these parts are equally important in setting the framework to provide excellent patient care. We aren't able to treat patients without a building to practice in, equipment to use, and systems to collect payments, for example. I imagine the variety of responsibilities may be overwhelming for some physical therapists and stimulating for others.
Are you asked to assist with maintaining the equipment in your facility? Do you participate in patient billing? Do you work closely with the landlord of your facility, or schedule fire marshal inspections when needed? How do you balance the multiple hats you wear? How do you multitask your multiple responsibilities?
When I was in my outpatient neuro clinical rotation I learned a lot from my instructor about PNF skills as well as standing, kneeling and seated balance training. It was a lot of hands-on work and we didn't use a lot of equipment other than parallel bars and balance pads, and a mat table. The clinic set-up was simple yet effective; patients had what they needed but not a lot of high-tech gadgets I've seen at other facilities.
After graduating from physical therapy school, I became very familiar with budgeting. Every dollar had a place. That same budgeting concept probably applies to every physical therapy clinic. How do owners, supervisors and physical therapists prioritize their equipment needs? My style of treatment and the equipment I need to practice effectively may be very different from my colleague who requests entirely different supplies for her patients. What is the best way to mediate those differences so all patients have what they need during a physical therapy appointment?
There may be ways to offset an immediate equipment need, but it's also difficult to substitute for some supplies when you don't have them. Parallel bars offer a lot of functionality that can't be easily mimicked if they are needed by a patient. The best example I have of needing equipment at the right time was when I assisted patients with gait training in an inpatient setting and my patient was ready to transition from a wheeled walker to a cane. Finding a cane was somewhat difficult because they always seemed to be propped in a corner of a patient room, so I often used my hand as assist although this wasn't the same as the patient handling a cane independently.
This topic of equipment also ties in with the "lean" concept I wrote about two weeks ago. How do we make sure our clinics aren't wasteful with equipment and supplies? How do we remove excess or unnecessary equipment from our clinics? And, how do physical therapists think when budgeting for equipment and supplies? Do we invest in what patients need, in what we can market, or in both?
Have you read ADVANCE blogger Allison's post this week about her first resignation from a physical therapy job? It sparked a lot of comments (mostly about the PTA role), but it also got me thinking about her comment on "greener pastures."
We all often consider the pros and cons of various employment opportunities, like any other profession outside of physical therapists. I remember two years ago thinking about my commute time, skills I would be able to practice, scheduled hours and my colleagues when I made the switch from inpatient to outpatient. Now as a rehab supervisor, I'm much more conscious of the rehab team's engagement, morale, and overall satisfaction with their jobs. Patients like to be cared for by therapists who like their jobs. We've all had experiences with an unhappy staff member in any setting and know our experience as a customer or patient was impacted.
My mom recently told me, "The grass is greener where you water it" -- a saying I'm sure she heard or read from someone else. Does this ring true to physical therapy jobs? Can physical therapists invest time and energy into making their own job a place they want to be?
When I first started working as a physical therapist, I was so motivated and felt such a surge of independence -- my years of education had finally culminated in an actual profession, including a job which gave me a paycheck! I was so excited to work, I didn't really stop. After about a year-and-a-half I was very burnt out. My energy was gone, I had a hard time concentrating and an even harder time connecting with my patients as I normally did. When it happened, I was surprised and felt badly because I knew my patients deserve better than that. It was a good learning lesson for me -- to recognize the signs of over-working so I could take a step back and pace myself.
What do you think? Are you a happy employee? What do you do each day or week to make sure you stay balanced? If you don't get what you want or need from your job, what steps do you take to get it?
When I worked at the hospital, there were times when I needed to grab linens for my patients during our physical therapy sessions. Gowns, towels and even bed sheets were frequently changed. The hospital floors each stored linens in a slightly different manner to fit the best workflow for their staff -- some linens were kept in cupboards outside each room, some in centrally located carts, and some in the patient's room. I remember a handful of times where I spent easily 5-10 minutes walking around the hospital floor, opening cabinets and peaking behind doors to find the linen storage, and to find linens that were stocked.
It wasn't until I started at my current facility that I learned about the concepts of "lean" and "continuous improvement." What is lean? Well, I'm not an expert, but my understanding is that lean assesses workflows to make them more efficient. One example I've been told is rearranging equipment (such as fax machines or copiers) to a location where it's more accessible. Instead of walking 9 seconds to the machine and 9 seconds back to your workstation, arranging desks and the machine so the average walking time is 4 seconds, gaining 5 seconds per fax transaction, that over time will become time to be spent with patients.
Looking back at my experience in the hospital, I recognize the linen storage wasn't the most resourceful. Why weren't cupboards labeled, or signage posted to find linens? Did other staff spend as much time as I did looking for supplies, and how much cumulative time was spent away from patient care in tracking down items? It would be interesting to see a "before" and "after" to demonstrate how changes to simple things such as adding a label to a cupboard equates to improved staff morale (having the tools to do your job, feeling empowered to find what you need) as well as increased patient time.
This makes me wonder if lean or continuous improvement processes will become common language in physical therapy. If you were to open a clinic today, would you consider the lean perspective in how you set up your practice? What has your experience been in continuous improvement?
I remember my neurology professor at physical therapy school would frequently joke that her friends didn't understand what type of work she did. She would say "physical therapist" and they would assume orthopedic injuries and ask for help with their necks, backs, and other musculoskeletal concerns. She would politely correct them and explain her focus on traumatic brain injuries, spinal cord injuries and strokes, and encourage them to find a physical therapist with the skills to help.
This happens to me occasionally, but not frequently, and I'm usually able to find a resource for my patients. For cases needing a women's health or significant hand rehab, I have community contacts for patients. Within my own department and network of colleagues, I know the experts on vestibular treatment or rib mobilizations I can connect with for refreshers when I'm a little rusty on my skills.
But, what happens when you have to say no? I recently had a friend from high school email me asking for advice for treatment for her child with ambulatory deficits due to a congenital disorder. She and her family live in a rural area in Alaska with no nearby options. I shared her story with some of my pediatric physical therapist friends, but we all agreed the case was too complicated to discuss remotely. We considered using FaceTime or Skype to provide some solution, but the child's needs required hands-on care.
I felt terrible. A big reason I chose to become a physical therapist was to help other people, and this felt like a major failure. It was hard to know the child needed help and I knew physical therapy could help, but couldn't provide any intervention. My friend responded with, "That's okay, I understand," but I still didn't have a good feeling about how the story ended. How do you handle cases like that? When you have to tell patients you cannot treat them, what alternatives to you provide? What's the best way to promote physical therapy when our specializations may leave us limited in scope.
Over the past few months, I've heard more and more about the patient-centered medical home (PCMH) model of healthcare. I typically think about healthcare models in the silos my physical therapy clinical rotations were centered on: inpatient, outpatient, or a skilled nursing facility. The idea of healthcare facilities as a "home" elicits a nostalgic and sympathetic response for me -- at last! Healthcare can be a collaborative home instead of an insurance-led, difficult-to-navigate entity.
So, what is a medical home? The idea started in the late 1960s by the American Academy of Pediatrics and has seen serious development in the past 10 years. A PCMH is a team-based delivery model led by an MD, PA or NP to provide comprehensive care to patients. The team facilitates continuity of care (majority of appointments are with the same provider/team), follow-up on referrals, full accessibility to care, and the use of evidence-based guidelines to improve quality of care.
As a physical therapist, I think this model sounds wonderful. Too often patients seem to get lost in the gaps of care and a home model may prevent those lapses. Being able to work with a patient and report my clinical findings right back to the patient's care team is how healthcare should be delivered. I think this works well in an inpatient setting already, but in outpatient there are physical and operational barriers to working as seamlessly together.
Several news outlets last week reported on recent study outcomes of the medical home model, with disappointing outcomes in reducing costs or improving quality. The studies compared 11 quality measures over three years and saw improvements in only one for the medical home models.
I'm interested to see how the medical home model evolves over the next few years. What do you think? Do you practice in a medical home? Do you see improvements in patient care compared to traditional models of healthcare practice?
As I've written before, I enjoy reading books. Books allow me the opportunity to learn something new, and although they may not be directly related to physical therapy, almost always improve my professional practice. One of my favorite books, Blink by Malcolm Gladwell, for example, has no reference to physical therapy but helped me to understand good decision-making, which I saw improve in my clinical work. Now, while I enjoy the nuggets of information I learn during our department journal clubs, I wonder if there is an opportunity to expand the concept into a professional book club. Would other physical therapists be interested in reading books to stimulate ideas and conversation?
I haven't heard of any of my colleagues or professional acquaintances participating in anything like a book club. Even journal clubs are at times difficult to make time for, and sometimes the topic is too diagnosis-specific to be relevant to all physical therapists. Is there value in expanding the requirements of a journal club? Would others find a professional book club beneficial?
As I think about this idea, I'm certain it would be advantageous to make the group as well-rounded as possible -- to include other professionals outside of physical therapy. There have been many times when I've networked with nurses, IT, case managers and want to hear more about their perspective because it helps me understand the whole patient experience.
I know what you are thinking -- what books would be on my list? Well, I've recently come across a few books that I would love to read and discuss with other people. They include: The Oz Principle by Roger Connors, Tom Smith and Craig Hickman ("Getting Results Through Individual and Organizational Accountability"), Healthcare Kaizen by Mark Graban and Joseph E. Swartz ("Engaging Front-Line Staff in Sustainable Continuous Improvements"), and Sticking Points: How to Get 4 Generations Working Together in the 12 Places They Come Apart by Haydn Shaw. I think I could learn a lot from these authors and from a good discussion with others.
What do you think? Would you be interested in a professional book club?
(Editor's Note: Throughout the month of February, ADVANCE bloggers Lisa Mueller and Michael Kelley will post "Dueling Blogs," in which they argue opposing sides of the same issue. Topic #4 -- "What Is the Biggest Challenge to the PT Profession?")
When Michael and I discussed writing four weeks of "Dueling Blogs" in mid-January, we wanted the last blog debate to be an important one, and decided to contrast our opinions of the biggest challenge to physical therapy practice. We had no way of knowing then that the APTA was writing a similar story for the February issue of PT in Motion, with an article titled "Addressing the ‘Biggest Threat' to Physical Therapy."
Obviously, this is an important current issue in our profession. I couldn't agree more with the article's author, Eric Ries, who quoted a therapist saying, "The biggest threat to physical therapy, I really do think sometimes, is physical therapists."
We are by far the biggest obstacles to our own practice. I've had the privilege of meeting lots of therapists over the past few years through CE courses, APTA conferences and social media outlets like LinkedIn, and I'm always surprised by the low standards we accept.
Therapists who half-jokingly mention taking naps at work while volumes are low. Experienced therapists who honestly confess they don't understand the difference between timed and untimed codes. Therapists who believe ignorance is an acceptable excuse for billing and documentation errors. Therapists who work hard to give "unskilled" work to other professions, which directly reduces the scope of our work. If we don't take our profession seriously, no one else will.
So, how do we bridge the gap? How do we inspire all physical therapists to engage in their careers and be accountable to drive forward? I think this is where the APTA could flex some muscle (musculoskeletal pun intended). But, as I write this I'm wondering how I plan to be less of an obstacle to the future of physical therapy practice. What can I do? It isn't just the APTA that needs to step up -- I need to as well. I need to be more informed about the current events of my profession and help celebrate the small wins with my colleagues. I need to do a better job of educating my patients on the role of physical therapy.
What do you think? What is the biggest obstacle to physical therapy? Is it regulations? Third-party payers? Inadequate access to information? Employers? The APTA? I encourage you to get involved in the conversation by leaving comments below. It is only in truly understanding the problem that we'll be able to find a long-term solution to make the physical therapy profession even better.
(Editor's Note: Throughout the month of February, ADVANCE bloggers Lisa Mueller and Michael Kelley will post "Dueling Blogs," in which they argue opposing sides of the same issue. Topic #3 -- "Does the Inpatient or Outpatient Setting Allow Greater PT Practice?")
Since I graduated from physical therapy school almost five years ago, I've been lucky enough to have the opportunity to practice in both inpatient and outpatient settings. While they both provide unique advantages, I'm writing today to debate that the outpatient setting is better aligned with the fundamentals of physical therapy practice.
I remember making the transition from inpatient to outpatient practice and was stunned by the realization that patients of outpatient physical therapy seek out our services.
Patients drive to our building, sit and wait for us to work with them. This was the opposite of my experience with inpatient, where I frequently had to encourage my patients to participate in the most basic therapy sessions. It was such a compliment to know that my outpatient folks were going out of their way, making time in their day to see me. I know there are exceptions in every situation, but I think the outpatient setting highlights how well physical therapy services are understood, implemented and appreciated.
Inpatient facilities are commonly organized by pathologies -- hospitals will have a floor for patients with neurologic pathologies, a floor for patients with cardiac problems etc. For the sake of argument, I'm going to simplify that therapists follow those patterns and end up practicing basic physical therapy interventions (gait, balance) to very similar populations. There isn't a ton of diversity. Outpatient is quite the opposite. I can start my day with a cervical disc and end with prosthetic training. You have to be ready for anything that walks through the door.
Speaking of walking through the door, that's another advantage of outpatient practice -- fewer interruptions. While I appreciate the collaboration in an inpatient setting with other healthcare providers, physical therapy sessions were often put on pause for lab draws, X-rays, or visitors. These things are important, but I'm very happy in outpatient when the whole appointment time is spent on treatment, and not waiting patiently!
I think the biggest advantage outpatient physical therapy has over inpatient is the patient relationship. I enjoyed building relationships with patients in the inpatient setting, but generally the length of stay was very short. Outpatient is a little different in that regard; I typically see patients over several weeks. I feel like I get to know my patients better in the outpatient setting, and making those connections is the biggest reason I went into the PT profession.
What do you think? Is inpatient or outpatient a better location to practice physical therapy?