The Productive Therapist and The Productive Clinic Peter R. Kovacek, MSA, PT

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1 The Productive Therapist and The Productive Cinic Peter R. Kovacek, MSA, PT Format Interactive Discussions among equa peers Constructive argument Reaity Oriented Mutua Accountabiity Expectation Panning Who is The Productive Therapist? Many different peope can be productive depending on the setting and systems s in pace. Avoid overgeneraizations What can the typica worker do to be more productive? What is The Productive Cinic? Given the right peope, any system can work Given the wrong peope, every system wi fai What systems are most ikey to enhance productivity for the typica worker? The Productive Cinic 1

2 Professiona Financia Success What Does It Mean To Be Productive? Optima Quaity Quantity Reim bursement Cost Containment Financia Success Simpy - Getting More Done. More of What? --- a crucia question. Vaues determine what is important for your cinic. Treatments Visits Charges generated Cases managed New cases started Cost Reduction Strategies Ony 4 options Provide ess care Fewer visits Shorter visits Lower payro costs Pay cuts Work ower on the food chain Lower suppy costs Accept ess profit Improvement What Degree of Recovery Can We Afford? The Patient Recovery Continuum Higher initia return of investment Time from Start of Treatment Point at which payor may see itte vaue in continuing rehabiitation Staffing Ratios Impact of LOS on Staff Mix Therapists Therapist Assistant Aides Assistants Aide Aide Assistant Therapist 2

3 Staffing Requirements Costs in Typica PT Cinic Cinicians Required Payro Annua Visits per 1000 Members Capita Suppies Option 4: Less Profit Factors Affecting Productivity Systems within your cinic Management Cinica Cerica No one system change wi work in every setting Productivity & Quaity Are NOT Mutuay Excusive Which Management Systems are a Probem for You? In most industries, quaity increases as productivity increases -- to a point. To increase productivity, ty, do not assume staff can just work harder. Systems need to be changed to become more efficient and ess error prone. To make systems more efficient, they need to be thoroughy anayzed and standardized. Management structure Strategic panning Staff deveopment Manager deveopment Retention and recruitment Marketing and Pubic Reations Poicy deveopment and maintenance Accreditation compiance Management reports Payro processing Suppy purchasing Communication infrastructure MEETINGS 3

4 Management Structure Poicy/Procedure Deveopment Mundane but critica to efficiency Leadership VS Interference VS Apathy Time spent feeding the machine Type text Type text Type text Type text Accreditation compiance Competence VS Compiance Manager VS Leader Leader by vaues Manager by rues Baance Interference Liabiity Professiona autonomy Reporting Processes Creating reports Reading reports Using reports Ignoring reports Stop doing reports: Do anyone notice? Does it matter? Meeting Effectiveness Interface principes Mutipe time commitment/risk Principed meetings Agenda Time targets Meeting critique QI approach to meetings What is the best mechanism to accompish the goa? Meeting VS other options Which Cinica Systems are a Probem for You? Staff deveopment Continuing Education Cinica education Aide/Tech training/use Documentation ti Record competion Staff scheduing Patient transport Suppy purchasing Program deveopment Cinica efficiency Third party reations Documentation Systems Purpose Technoogy considerations Personne considerations Reaistic expectations 4

5 Purpose of Documentation Communicate To others To sef Liabiity Reimbursement Practice Anaysis Research Outcomes Technoogy in Documentation Hand written narrative Hand written forms based Logs and fow sheets Dictation/transcription Automated entry Bar Code Tempate word processed Scanned Voice recognition Data based Personne Considerations Wiingness to standardize Sophistication & experience with automation Keyboard skis Geographic dispersion of personne Abiity to support automation Reaistic Expectations Documentation is major source of compaints by staff Streamined does not mean eimination Documentation is ony source of credibiity to many externa agencies Avoid dupication and waste Reduce, Reuse, Recyce Productive Documentation Best Documentation Systems Standardized across staff and sites Max vaue, min effort Coection of data eements, not narrative Coordinated with outcomes Timey, attractive, meaningfu Patient Record of Harriet Handson Automated has many advantages Voice recognition is on horizon Standardize in hardcopy format before moving to automation Easier editing Less threatening Integrate with outcomes 5

6 Purpose of Third Party Reations Assure appropriate treatment Assure appropriate payment Joint probem soving Anticipate potentia probems Marketing of your practice Third Party Reations Interaction with Case Managers Interaction with MCO personne Phone processes Move to fax processes Deveop persona reationships Specific staff to specific case managers Specific staff to specific MCO Specific staff to specific referrers Give first, then receive Organizationa infuence within the MCO Board positions and Committee positions Which Office Systems are a Probem for You? Patient scheduing Staff scheduing Biing Insurance verification Script re-authorization Referra routing Record competion Suppy purchasing Routine typing, etc. Data gathering Report preparation Irreguar office procedures Scheduing Mutidiscipinary Scheduing Negotiated Unprinciped Miracuous Misunderstood Purpose of Scheduing System Patient/cinician matching Communication Interna Externa Et Record keeping and data generation Practice anaysis/research Preiminary Scheduing Issues Who contros schedue? Therapist? Cerica Staff? How to buid in accountabiity? Cinician Scheduer Who shoud access schedue? What additiona information comes from schedue system? 6

7 Technoogy of Scheduing Appointment books don't work in medium to arge cinics Automation advantages Dissemination of rea time information Reporting Reduction of staff/scheduer interface Mutipe simutaneous access Fancy system not needed Basic data base system works fine Automated Schedue System Automated scheduing VS automated record keeping Accountabiity Schedue management Who is responsibe for productivity? Computer? Therapist? Anyone? Scheduing Initia visits Bocks Waiting ist Recurring visits it Reguar times Inconsistent times Attendance issues Accountabiity issues Biing for Productivity Use CPT/RBRVS system Revenue codes in hospitas Negotiate new contracts CPT Under biing epidemic i Who assigns codes? Therapists? Cerica staff? Record Competion Incompete records are frequenty a source of payment denia Track competion as part of Patient Information System (Schedue) Reguar reports to cinicians with updates Buid into PPAS The Productive Therapist Peter R. Kovacek, MSA, PT 7

8 The Productive Therapist To become more productive, we first must examine those who aready are and especiay those who aready are not. Who is The Productive Therapist? Many different peope can be productive depending on the setting and systems in pace. Avoid overgeneraizations Therapist Skis Having more skis avaiabe does not mean that what you do wi be more effective Focus is needed Cautions Different setting means different productivity Different types of patients means different productivity Support systems wi have a tremendous impact on productivity No magic "god standards" What Leads to Productivity? Limit to outpatient orthopedic PT Probaby appies to other scenarios Study pairs of therapists Same physica pant Same resources Same patients Pair differ by 30% in productivity Visits, treatments, etc. Factors Affecting Productivity Therapist Attitudes Therapist Beiefs Quaity Acceptabe quantity Therapist Behaviors Biing choices Treatment choices Interaction with support staff Therapist skis 8

9 Study Design Interviewed 125 Tota Pairs Structured Interviews Information Gathering Voume (8-46 pts) Outcomes ( 20%) Type of oad (ortho) Hours worked 40+ hr/week Experience (>2 yr) Continuing Education Management experience Interviewed Word Cass Cinicians Five 40+/day therapists in fina group Not a goa - a mode Most can not reach this goa Or even come cose Use the best to get better Information Gathering Definition of quaity "Fu" oad When does increased quantity reduce quaity? What wi managed care do to your cinica practice? Biing practices & behaviors Method of income for therapist More Information Actions to increase productivity Cinica Business systems Documentation ti Typica patient interactions (Audio/Video) Initia eva Routine treatment Discharge Use of anciary support staff (30-40%) More Information Stress eve at work Perceived important actions for productivity, i.e. What has worked? Treatment paradigms Use of pathways or protocos Extent of productivity monitoring system 9

10 Reasons for Excusion N=50 Study Design Inadequate characteristic match Dissimiar hours Varying neuro/peds oad Inadequate quaity match Dissimiar outcomes Poor outcomes Poor patient satisfaction Observed poor quaity or interaction Anayzed Not Excuded Pairs Incuded Pairs The Productive Composite Tremendous variance within individua cinics and between cinics No reationship between stress and voume at steady state More stress when voume is increasing Few are not aware of need to increase Most therapists are concerned about quaity degradation The Productive Composite Individua skis matter Individua behaviors matter Productivity is a discipine Productivity requires discipine Bi - The Low Producer Fees somewhat disorganized Strugges with time management Tried daiy panners and organizers but nothing seems to work for him Thinks about today - today, not before Bi - The Low Producer Passivey accepts his schedue Often not sure what wi happen next Td Today, tomorrow, ater t in the week Tends to bames scheduer for his ess productive days Many discharges seem "unanticipated" 10

11 A Basic Requirement You can not treat what is not schedued You can not treat what does not show up Bi - The Low Producer Frequenty distracted in the cinic Phone cas Missing paperwork Patients out of schedue interfere Co-workers find him easiy avaiabe to "hep" with their patients Interferes with treating his own patients Bi - The Low Producer Misses meetings because patient care runs ate into meeting time Has to pay catch up for meeting information Considers meetings a waste of time Leaves ate Bi - The Low Producer Documentation Aways seriousy behind Hesitant to see more patients because of the "excessive" " paperwork required Does not reay have a "system" to get the notes done Bi - The Low Producer Contro of patient interactions Spends significanty more time with patients t but often needs to get more information ater Often pued out of patient contact time by interruptions Patient Perception of Therapist Time Bi Patient perception of contact time is skewed ow Phi Patient perception of contact time is skewed high 11

12 Verba Patterns Bi Uses big vocabuary and jargon Grade eve As high h as 22nd grade eve Phi Use singe syabe words Grade eve Bi - The Low Producer Fees that patient education is not as important as hands on time Verbay aows patient to reschedue or miss treatments in the name of patient service No show / Canceation rate doube that of Phi Sometimes fais to set mutua goas with patient Attitudes About Therapy Bi "Patients are here to get treatment from me" Patients "I'm here to get better" Bi - The Low Producer Speciaist attitude toward treatment of compicated patients When in doubt, uses a resources at his disposa to get the patient better Patients get a his skis - every treatment session Quaity According to Bi Defines quaity in reation to the amount of his time the patient gets, or that the treatment is done by a skied Therapist Quaity vs Quantity Lower producers Increased quantity is perceived to absoutey reduce quaity Doing more means doing it ess we Higher producers Increased quantity is perceived to potentiay reduce quaity Doing more means getting more done, it may or may not affect quaity 12

13 Therapist vs Patient Focus Lower producers Define therapy from the therapist's viewpoint Good therapy is when the therapist is good Patient is a recipient of good quaity Therapist centered focus Therapist vs Patient Focus Higher producers Define quaity of therapy from the patient's viewpoint Good therapy is what works Patient is an active partner in good therapy Patient centered focus Phi - The High Producer Highy Organized Uses a daiy panner reigiousy Prepares the night before eaving Emphasizes scheduing Can't treat what doesn't show up Assured patient understands need to attend - does not give permission to miss. Anticipates discharges and pans ahead Phi - The High Producer Contros extraneous cinica distractions Phone interruptions Prepares a very seect ist of acceptabe interruptions Schedues time to return cas Schedues a time to take cas Peer interruptions Shares cinica techniques but for patient reasons not socia reasons Phi - The High Producer Meetings Attends on time Requests agenda Encourages time imits it in agenda Phi - The High Producer Documentation Competes notes whie with patient Documentation becomes part of the reguar treatment session May use any of many technoogies for notes Whatever the technoogy, uses a system to make it work to his advantage Keeps up - rarey fas significanty behind 13

14 Phi - The High Producer Contro of patient interactions Outstanding istener Intense eye contact Patient t perception of contact t time is skewed high Uses simpe anguage and few mutisyabe words to expain Backs up verba with written instructions Initia Patient Interaction Does not give permission to miss Promises reaistic goa attainment Goa Setting Draws verba picture of successfu competion of therapy Phi - The High Producer Beief Therapist is there because the patient needs them, not the patient is there for the therapist t to treat t Tiered approach to care Phi - The High Producer Expert, not speciaist attitude Emphasizes what works, not techniques High emphasis on patient's roe & responsibiities Exceent patient educator Prefers to educate rather than hands on when appropriate Focus is on patient - not therapist Tiered Patient Care Focus on effective Not efficient Not "Cadiac-approach" When singe preferred course is not obvious, chooses singe or few interactions, not a itte of everything Rife, not shotgun approach Starts with east risk, east cost course that is ikey to be successfu 14

15 Tiered Patient Care Progresses, if needed, to next owest cost, next east risk course e.g. Hypertension intervention Terminates treatment when goas are reached or it is cear they are not ikey to be reached Termination decision more comfortabe Use of Anciary Caregivers Deegation won't hep if: You are not good at it No one to deegate responsiby to Define capabiities and avaiabiities as a team Bad supervision worse than no deegation at a Define roes Education Experience Expertise Keys for Deegation Decisions Critica Factors to Consider Separabiity of Tasks Predictabiity of Consequences Stabiity of Situation Observabiity of Basic Indicators Ambiguity of the Situation Criticaity of Resuts Phi vs Bi Neither one is bad person Responsibe Hard working Dedicated d Neither one is Mr. Wonderfu Phi is just more productive Everything ese equa - more productive is better Pays own way better Changing staff behavior Staff aready knows importance of high productivity Carify its importance in your cinic Hep staff anayze Phi and Bi What can staff adopt from Phi and avoid from Bi? Staff needs to "hande" productivity to reay earn it 15

16 Acceptance of Change Externa/Environmenta Denia Commitment Overcoming Resistance Convert Imposed Change to Initiated Change Danger (Past) Resistance Interna/Sef New Awareness Opportunity (Future) Done To Us Done By Us Handing the Concept Rubik's Cube approach Don't just te about it Hep staff experience it Some of the rues are not known Many years of practice may need to be unearned Everyone does it "their best" Skis are tedious to earn Even more tedious to unearn Ask Staff Questions What is quaity? When is it too much to be good? What have you done to be more productive? What is your documentation system? Are you a good deegator? Is therapy about you or the patient? And keep istening Then isten Productivity wi chaenge your vaues Carify them Remember to focus on what is important - ike Phi Don't get frustrated 16

17 Become The Productive Therapist Peter R. Kovacek, MSA, PT PTManager.com Thank You 17

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