In seasonal waves, the discussion on professional engagement and accountability ebbs and flows with interest to apathy. It seems no matter what, there is always a segment of of any profession which has highly passionate and engaged individuals. Sadly, there is a matching (if not outnumbering) sum of complacent individuals who represent mediocrity, or worse.
So how do we beat this? How do we solve this ugly truth where, especially in the world of physical therapy, we severely lack systems and standards for professional accountability?
How do we make cause for professional engagement on a new and elevated level? Can we even influence it? What are the tools to do so? Would such systems require routine maintenance?
Before I continue, I’d like to propose that all things being equal, human behavior falls in line with the laws of thermodynamics; the 2nd law to be precise – entropy – conceptually, that all things tend to spin into disorder and disarray. And so, unless specific systems are in place to guide, reward, punish, modulate, limit, and inspire human behavior – let’s face it, laziness will get us all and everyone will eventually become complacent.
I propose that the best systems to lay are those of strong foundations in encouraging professional accountability. Even more so, it must be married with systems that affect the function of life reality – the elemental motivation to why most of us have our jobs – we have bills to pay, mouths to feed, etc.
Some of these concepts include modified productivity scales, new roles for physical therapists, diagnosis group modifiers for productivity vs. efficiency, modified commission salary for retail business models such as in the outpatient setting.
However, accountability goes beyond basic employment measures. Accountability requires engagement and being honest about what really makes us awesome… and what really makes us dismal as a profession; we need to talk tracking clinical outcomes, customer satisfaction, peer regard/respect, operational/financial efficiency, and brand value contribution which is inclusive of interdisciplinary professionalism and rapport.
So then, after this VERY long introduction, let’s get into the meat of things!
The Meat Of Things
The only way we can even begin to think of making our profession accountable is to make sure that the management systems are in proper place. Why do I say this? Because all too often, those who are content to fulfill the minimal employment requirements for the job description stay in companies for a very long time. By default, these unengaged individuals become leads, supervisors, managers, directors, and even vice-presidents and chief executives. Why this madness!? Human nature.
I propose that the precursory goal to founding true professional accountability is to promote those with leadership potential into management positions. I further propose that their managers must support them closely as to avoid for very quick burn outs (which is terribly common). These individuals can now support those with clinical talent and acumen so that they don’t burn out. You can see the cascade. In effect, we need good leaders in management positions to control the influx and exit of the good and the bad alike. Ultimately, all physical therapists serve as employees in part of a firm. Good leaders must be raised into positions where by structure of employment, those who are valuable to the profession will be supported & promoted. Likewise, those who have performances much to be desired, can be properly coached, encouraged, instructed, suspended, and/or employment terminated. The beginning is just that simple.
If this critical foundation isn’t laid, then the never ending cycle promoting the overpaid, overrated, and ridiculously regarded for the measure of years of service to a company by meeting minimal HR requirements on a yearly basis will continue. Those who are trying to carry the weight of the profession forward will continue to burn out. And, let’s be honest. We all know this is true.
Engaging Physical Therapists
There are several ways to place true value upon years’ end, performance appraisals for employment in a manner which will truly engage physical therapists. Nothing is more discouraging than to know one is a hard working and effective clinician, only to be given minimal regard at the end of the year. I propose the following five measures as a method of engaging physical therapists by managing for good performance. These are:
- Clinical Outcomes
- Patient Satisfaction
- Peer Review
- Operational Efficiency
- Brand Value Contribution
Tracking Clinical Outcomes & Patient Satisfaction:
These two elements are quiet easy to track. They can be done in the form of phone, email, snail mail surveys from patient/family response. They can also be done through electronic health records when it comes to clinical outcomes. Whatever objective measure is used per diagnosis (or group of diagnoses), such can be compared amongst the peers of each department. Even better, should firms share their data across the board, managers can easily identify outliers on both ends – the clinical experts with the best outcomes, and, those who may be struggling with poor outcomes. After all, isn’t it best to judge employees by how they perform and how their customers perceive them to perform?
Utilizing Peer Review:
Peer review is always tough. In fact, so many times, this becomes a popularity contest with severely tainted data. “Who do you have? Oh, we have each other! Be nice to me, and I’ll be nice to you!” Sound familiar? *barf*… Indeed.
I have a story to share which will perhaps open up ideas for new channels regarding peer review.
I was once privy to an event where a firm decided to take senior clinicians and compare their skills against academic professors. They came up with definitions for basic, intermediate, and advanced competency criteria and skill sets. Once they defined black and white boundaries to their qualifiers, each clinician was observed performing an evaluation, a treatment, and a discharge. Out of approximately 20 clinicians, three were dismissed for being clinically unsafe.
What’s the lesson? The peer review should be primarily clinical. Mind you, the judgment wasn’t on if one clinician was to treat with one method versus another. The critique came from the perspective of clinical safety, rationality and appropriateness of the patient encounter, and perceived professionalism from peers. This had nothing to do with manual therapy versus pain science or SFMA vs. MDT. This had everything to do with physiological safety, the mannerisms with which clinicians were conducting themselves, and the rationality of their choices during patient care.
Sounds tough? Yeah, you better believe it is. It’s tough to be honest under pressure, watched by hawks.
I use the term efficiency over productivity because I feel these are two separate issues. Most firms measure productivity as billable patient care divided by total facility time billed to the company. However, there are so many nuances in patient care for each setting that I feel efficiency is a better measure.
I define efficiency as an employee’s contributory value to the operations of any firm. Certainly, productivity is a part of this measure. However, it must differ per setting and purpose.
For example, in the SNF setting, so very much can be completed during point of service. Therefore, documentation time, set-up time, patient education – all these things can be done during “productive” billable moments. However, in the outpatient setting, it can be more difficult perform as such. In the acute care setting, this is nearly impossible. Just imagine, trying to monitor vitals and stress response in the unit while documenting on a portable tablet or station on wheels.
Therefore, each setting must have its own criterias of “efficiency.” As mentioned above, in acute care, productivity modifiers must be in place for each DRG. After all, a physical therapist can easily evaluate three or four patients in the short stay observation unit or on a medical floor before a colleague is done with even two treatments in the ICU or neuro/trauma floor. Agreed?
There is also more to the story of efficiency. In the settings where productivity is highly variable (this shouldn’t include rehab or SNF, really), employees should have some command over their effect of cost on the company. One of the best models of this I’ve seen is the outpatient commission model. Staff is given a base rate/salary and is paid additionally per units billed. In this case, staff is highly motivated to stay productive, otherwise, they simply don’t get paid as much.
Brand Value Contribution:
I feel that a physical therapist’s brand value contribution is a behavioral component of professionalism. The regard that interdisciplinary teams on physical therapy departments, the external demand from patients for a local physical therapist, the amount of contribution given via social media presence, or perhaps professional representation at fairs, expos, and health conferences – all these are truly valuable to the building, strengthening, and expansion of the physical therapist’s brand.
This also includes curbing damaging in house behaviors. By this, I mean the irksome examples of: “Hi there! I’m from therapy. Time to get out of bed.” Or perhaps, the misrepresentation of PTA’s who do not bother to correct their customers when addressed as a “PT.” This can also include missed opportunities in sharing the breadth and scope of physical therapy to curious or otherwise unaware future customers.
On a positive note, brand value contribution is also noted when health systems consistently highlight physical therapy staff as signature moments in commercials and other media outlets. When staff is noted on local television, radio, or print ads – they should be recognized and encouraged within their departments.
But the question remains, how would/could a manager measure brand value contribution for a yearly performance appraisal? I would suggest a combination of self reporting and peer observation (once again, the peer review… sucks to be judged, huh?) It’s a bit tough to say “Oh yeah..! I’m on Twitter all the time. I chat it up and try to build up our brand value as PT’s.” — “Ok…. Have you heard of #brandPT? No?”
Errr! *BUZZER* – and – Fail.
The Wrap Up
The fact of the matter is that professional accountability doesn’t exist in good form because there are no management/HR systems present to do so. Mediocrity is rewarded. Excellence is judged as an unwelcome “showing up” of those who are seniors in any given company. Passion is quickly burnt out. Longevity is considered expert and regarded as high quality care. New grads are considered cheap labor.
Until such issues are fixed via improved management systems, new policies and procedures, new measures for performance appraisals – human nature will continue to reign. People get lazy. People become unmotivated. People get discouraged and eventually stop caring.
BUT! Think about a system where excellence is truly rewarded. Acumen is groomed into leadership. New grads are valued for the incredible contributions they bring. Experience is cultivated to strengthen an entire department, not conserved as a secret for fear of becoming irrelevant. Imagine an environment where it pays to be good; where optimum performance is openly recognized and rewarded.
You want accountability? You want the MAJORITY of physical therapists to be engaged? To be passionate? Do you want our profession to have a unified front of excellence in the eyes of our consumers and our healthcare allies?
It starts with our managers. My challenge has been issued. Who will accept it?