On the Job

A clinical practical perspective for the treatment of the injured worker.

By Larry Briand MS, PT, ATC and Emily Monson, PT

You will quickly recognize that managing a worker’s compensation patient often requires a greater level of commitment to communication, as there are many parties involved in the care and recovery. Physicians, case managers, insurance adjusters, and employers are all included in the evolution and advancements in a plan of care, including physical therapy. A physical therapist specializes in movement and functional performance of daily living, and provides us successful outcomes for all types of injuries; whether caused by poor posture, body mechanics, repetitive overuse, or trauma. We have a terrific opportunity to impact work-related injuries and we must focus on all components of a work-recovery care plan. This includes details, such as the specific job demands, current functional limitations of our individual patients, related to his or her work duties, and recognizing all of the key players involved in his or her recovery.

To identify all variables in a worker’s compensation case, seek to gain a full understanding of the job demands. Creating and utilizing intake forms provides a thorough history incorporating job specific questions [(figure 1)] and allows us to gather information pertaining to a patient’s job demands, including lifting, pushing/pulling, reaching, carrying, and the weight and frequency to which the tasks must be performed. Complementing documentation can include job descriptions obtained from the patient’s employer. If this is not available, the Dictionary of Occupational Titles (DOT) can also provide more general information on the physical demand level of the particular job. A best strategy to gain accurate and detailed information on an injured worker’s job expectations is through an on-site visit to the workplace. This strategy allows the therapist to obtain a complete appreciation and understanding of the worker’s duties needed to fully rehabilitate that patient back to their prior level of function.

On-site visits allow us the most accurate means of visually assessing a worker to their job. There are many benefits to scheduling a site visit early in the plan of care, including being able to incorporate this information into the treatment plan. The information collected from your created job demands form at the evaluation can be an essential tool in alerting you in advance of what you should look for on your visit. Having the patient accompany you to the visit is a helpful way to gather additional knowledge by looking specifically at them in their work environment. Studying the patient’s work station, posture, work set up, ergonomic situation, physical job demands, and rate as to which they are needed to perform their job tasks, will allow you to better conclude functional goals, work simulation tasks, and determine potential modifications to prevent future injury.

Job site visits require time out of the clinic, so training another licensed professional, such as an athletic trainer, exercise physiologist, or a physical therapy assistant on how to properly complete this assessment can be of great value. The data collected can establish more functional tests as you create progress notes to update their physician and case manager as to how they are doing. With a more functional progress note, we are able to objectify our patient’s progress with comparable data specific to work movements, material handling requirements, and progress to specific movement needs. This is more specific than typical measures of range of motion, manual muscle testing, and pain. The combination of these efforts will allow you to best understand and simulate job tasks within the clinic environment and help you determine when a Work Conditioning/Work Hardening (WC/WH) program is appropriate for more dedicated attention to obtain full return to work at their previous level of function.

Job simulation is imperative in successfully returning the patient to work safely and efficiently. It also provides an opportunity to get the patient physically and psychologically ready for the work that had initially caused injury. A comparable example is the athlete that will return to a court sport. This individual must have confidence with running, jumping and cutting needs prior to any sport return. This will take place in a safe and controlled environment like your clinic. An “industrial athlete” is no different. Physical capabilities are important to accomplish, not only for modification updates and future release of work restrictions, but also for the psychological readiness that goes into work return. The opportunity to practice his or her job prior to return with tools or materials from the company is an excellent way to accomplish this. A more dedicated program that includes work simulation and work time is a work hardening and conditioning (WH/WC) program. Once the program is complete, a functionally-based discharge summary will measure the progress and/or any limitations. This information will assist and facilitate physicians more accurately and specifically determine work restrictions/modifications or disability ratings as they return our patient back into the work environment.

The more specific and function-based documentation that is generated will assist the patient, the physician, the case manager, employer and payer. Proactively offering in-depth communication with the case manager and payer will help them better understand the patient’s need for therapy, securing claim status. The employer will also benefit from proactive communication as it shows the level of involvement invested in the care of their employee. By showing the value of your services through the worker’s treatment, you may develop future opportunities for on-site work including educational seminars, stretching programs and ergonomic training. Becoming further involved with the employer may also lead to additional therapy opportunities to becoming the preferred provider of choice by the employees and their families.

Understanding and incorporating a patient’s specific job demands into the care plan so we may better return them to work in a safe and timely manner. Implementing the information early including the job demands questionnaire, a job description, and performing an on-site visit to give us a full appreciation of the worker’s tasks and assist us in creating a well-rounded plan of care. By incorporating all of these pieces into the worker’s compensation case, we have the ability to show the true value of our services, while returning the injured worker safely back into the workforce.

Emily Monson, PT, is an Impact editorial board member and owner of Clear Lake Physical Therapy and Rehab Specialists. She can be reached at emily@therapy1.net.

Larry Briand, MS, PT, ATC, is a PPS member and chief executive officer of Rehab Management Solutions in Sturtevant, Wisconsin. He can be reached at lbriand@rehabmgtsolutions.com.

Keeping Staff Accountable

How to keep employees on task—without being big brother.

By Carl Mattiola

Physical therapists in private practice measure objectives when it comes to our patients. However, when we step away from patients and focus on running our practices, we do not often know what to measure or how to measure it. One critical measure that elicits a great deal of discussion, emotion, and controversy is employee performance.

Why the controversy? I have heard myriad excuses from colleagues:

“It will take too long to set up.”

“Collecting data is too Big Brother-y.”

“Staff will be resentful if we evaluate them by the numbers.”

“It’s micro-managing.”

“It’s messy.”

“Our system works fine the way it is.”

However, that is not necessarily the case. Accurately tracking performance is one of the best ways to improve your physical therapists’ productivity and increase their job satisfaction.¹ As Jason Richardson, vice president of clinical operations at Results Physiotherapy says, “If you cannot measure it, you cannot influence it.”

Measuring performance can help in the following ways:

Practice owners can get an objective view of their clinicians’ areas for improvement and overall potential. In addition, access to accurate statistics makes it easier to start crucial conversations about performance.
Physical therapists will have a clearer picture of their job—what is expected of them and how they can meet those expectations. Employees who understand how they are being assessed are more satisfied than those who feel their role is ambiguous.² With a clear path to follow, clinicians are in control of their destiny.
Patients will benefit from an efficient practice, staffed by satisfied employees.
Your practice’s productivity will increase, and so will the bottom line.

How should you measure performance in your practice?

They key lies in your company culture. In fact, it is the single most important factor in implementing any new system. Start by explaining your goals in a way that shows the benefit to everyone, and take time to listen to employees’ concerns. Sturdy McKee, chief executive officer of San Francisco Sport and Spine Physical Therapy, has had great success with implementing employee accountability. His advice? “Keep the lines of communication open and you will manage change more effectively. Change implementation will take longer than you expect and will remain a work in progress for a long time.” Reinforce that this is a positive tool to help everyone improve.

Once your team is on board, establish key performance indicators (KPIs) for each physical therapy. “Each therapist in our company shares these metrics at our weekly staff meeting: visits, attendance rate, new patients, discharges, percentage of discharges, and how they look for the upcoming week,” says Chad Madden, Founder of Madden Physical Therapy. “If there is an area that needs attention, the physical therapists reveal to the group how they plan to improve over the next week. This makes it easier on our management team because each physical therapist is accountable to the entire group. If they have a percentage of patients falling off on plans of care, the physical therapist can see how it affects the group. With good staff in place, it becomes self-regulating and a win-win for everyone.” (Learn more about establishing KPIs here (http://www.ppsimpact.org/setting-goals)

Next, discuss each individualized plan with your physical therapists. Explain what you will track and how often you will check on their progress. Use this conversation to motivate and energize employees by letting them know you anticipate great things from them. According to Dr. Eric Bull, chief executive officer and co-founder of Spine and Sport, “When people know what they are there to do and then you measure it with a statistic, it actually gives them a good feeling of job security. People tend to like it when it is done well.”

One this reporting is in place, track your KPIs. If you have a practice management system in place, you already have a plethora of information available. Make the effort to consistently pull, review, and share the data. When you do this regularly, metrics become a normal part of work life, not something to fear. Even if there is initial trepidation, McKeever says, “There are a lot of emotions that come into all of this as we learn and grow and change, and that is okay. We all have room to grow and learn.”

Practices across the country have found this process to be helpful. There are also few unexpected benefits:

You will notice immediate opportunities for change. “The first thing we found was that about 50 percent of our total patient referrals came from two positions. If something happened to one of those people, that could be a significant change to our business and might affect our survivability,” says McKeever. They immediately began broadening their marketing initiatives to widen their referral base.
Staff will rise to the occasion, with performance improving across the board.³ This unique phenomenon is called “Metric Motivation,” and it occurs when public recognition from employers ignites extrinsic motivation among employees.
Your best employees will excel further and be happier. Even though they are already high performers, bringing hard numbers into the mix often inspires additional achievement.
Your lowest performing employees may turn over. Or, they may finally have the role clarity they need to improve.
When your physical therapists are happier, your patients will be happier; you may even see an increase in those who come for their full plan of care. You might worry that increased productivity will reduce quality of care, but it should not. Maximizing your clinicians’ performance is about positive motivation, not about cutting corners.

It has been proven that in almost any business, happier employees and happier patients add up to a happier bottom line.⁴ So it is no surprise that practices that value productivity outperform those that do not. Start measuring clinician performance today, and you will be measuring increased revenue tomorrow.

Carl Mattiola is founder and chief executive officer of ClinicMetrics. He can be reached at carl@clinicmetrics.com.

References:

1. Bohannon RW. Productivity among physical therapists: an evaluation of one department. Phys Ther. 1984; 64: 1242-1244. Available from: www.physicaltherapyjournal.com/content/64/8/1242.full.pdf Accessed June 16, 2014.

2. Hurrell, Jr., Joseph J, Levi, et al. Encyclopedia of Occupational Health and Safety. Jeanne Mager Stellman, Editor-in-Chief., Geneva: International Labor Organization; 2011. Available at: www.ilo.org/oshenc/part-v/psychosocial-and-organizational-factors/factors-intrinsic-to-the-job/item/21-role-clarity-and-role-overload. Accessibility verified June 16, 2014.

3. Human Capital Institute. The value and ROI of employee recognition: linking recognition to improved job performance and increased business value—the current state and future needs. Available at: www.marketing.org/files/Value_and_ROI.pdf. Accessed June 16, 2014.

4. Harter JK, Schmidt FL, Hayes TL. Business-Unit-Level Relationship Between Employee Satisfaction, Employee Engagement, and Business Outcomes: A Meta-Analysis. Journal of Applied Psychology. 2002; 268-279.

Secure Your Practice’s Bottom Line

The key to providing cash-based pre-habilitation services.

By Larry Briand, MS, PT, ATC

Workers’ compensation costs and high Occupational Safety and Health Administration (OSHA) recordable rates are devastating to companies. When a workplace injury occurs, employers are forced to pay large medical claim expenses for the injured worker, account for productivity loss, and train additional or new staff members. Unfortunately, most employers do not realize that many workplace injuries stem from poor body mechanics and repetitive strain injuries (RSIs). With these injuries and accompanying costs on the rise, companies are seeking cost-effective injury prevention programs now more than ever. As rehabilitation experts, we can become their resource by providing on-site consultation and/or first aid services. Through such pre-habilitation solutions, you not only become your community’s destination center for industrial medicine, but also secure your practice’s bottom line through cash-based services.

Workers’ compensation claims are at an all-time high. In 2011, the average direct cost per medically consulted workplace injury was $37,000. This includes the estimate of wage losses, medical expenses, administrative expenses, and employer costs. In addition, there were 5,000,000 medically consulted injuries caused in the workplace.¹ Although not all companies face large workers’ compensation claims, others are affected by high OSHA recordable rates. High rates also create a large frustration for employers; the higher this rate, the higher the cost of workers’ compensation premiums to the employer.

To combat this, many employers have implemented injury prevention programs, including stretching programs, but complain that employees are “just going through the motions.” Being a rehabilitation professional, you understand the common musculoskeletal injuries and RSIs that can occur on a day-to-day basis. Because of this, you are able to implement the most effective pre-habilitation programs to help employers reduce injuries and costs. In fact, companies that hire physical therapists for on-site preventive services have been known to decrease injuries by 75 percent.²

Now that you realize your full potential and the value you can bring to local companies, you may wonder “Where’s the best place to start for business-to-business networking?” I am a strong believer that the best marketing tool is a patient’s testimonial and word-of-mouth referral. Use this to your advantage. If you currently have any workers’ compensation patients in your clinic, see if they would be willing to discuss their experiences with their supervisor or human resources manager. If possible, see if the patient is also comfortable providing you with this individual’s name and contact information. By networking this way, you show key decision makers that you already have a connection with the company. You may also be able to offer valuable insight on how your preventive services could have assisted in avoiding your patient’s injury. Other business-to-business networking opportunities include attending local Rotary club and Chamber of Commerce meetings. If allowed, ask if you can lead a meeting and demonstrate some simple injury prevention techniques to stir questions and interest. Lastly, there is the cold-calling method. The key to cold calling is persistence. Even if a company does not seem interested at the initial contact, “extensive marketing studies have shown that the typical customer must have at least 17 impressions of a brand before they consider trying it.”³ Don’t be alarmed if you hear the dreaded “not at this time” response. Stay in the forefront of the company’s mind to create “mind-share real estate,”³ or the practice they think of first when they are ready to implement preventive services.

Once a company shows interest in your preventive services, focus on scheduling a meeting with the key decision makers, such as the human resources manager or safety manager. Use this meeting as a mini presentation period to showcase the value of your services. If possible, invite someone from the safety committee to the meeting. Prior to presenting, be sure to do your research—do not go into the meeting unprepared! Internet searching will allow you to determine the type of job tasks that are most likely to be performed in the company, as well as how many locations are offered, and the company’s mission/value goals. In addition, ask your main meeting contact plenty of questions to learn:

How large is the company/number of employees?
Are multiple shifts offered?
How are employees recruited (staffing agency or direct hire)?
Are any preventive services currently being offered and are they effective?
Are there any commonly seen injuries occurring?

By learning the answers to these questions, you will be able to tailor your presentation to the company’s needs. Remember, no one cares how much you know until they know how much you care. By offering a solution to the common problems facing an employer and showing that you care by taking the extra time to research their needs, you become valuable. As I like to phrase it, when you make it all about the other person, it becomes all about you. Stay calm during the meeting and answer all questions as accurately and fully as possible. Be careful not to falsely advertise or over-promise things you are not able to provide.

Dependent upon a company’s needs and issues, several on-site solutions are available that you may be able to provide including:

On-site First Aid Services: Schedule regular hours at a company where employees can visit you to discuss their aches and pains. The goal is not to provide clinical treatment, but to offer first aid services and advice before an ache turns into an injury/recordable. This includes education, applying heat or cold, and/or massage. Provide posters to encourage employees to visit you during your scheduled hours.
Ergonomic Assessments: Although most employers are now familiar with the term, many do not realize that an employee’s workstation must be modified to fit the employee to prevent RSIs, not the other way around. As an expert in RSIs, you can become a valuable resource by offering simple and cost-effective ideas on how to tailor an employee’s workstation to avoid potential injuries waiting to happen.
Stretching Programs: When implemented correctly, stretching programs can be of great value. Not only do they help prevent injuries by increasing an employee’s flexibility and range of motion, but also improve circulation, coordination and posture, and help reduce stress. Ideally, stretching programs should be available at each shift and tailored to each employee’s position.
Fit-for-Duty Testing: Whether performing post-offer pre-employment (POPE) testing or making sure injured workers entering back into the field are fit-for-duty, be sure that you are compliant with applicable laws and understand all testing rules and regulations. For example, if providing POPE testing, you must test all individuals for a specific department/position and remain unbiased through objective testing.

Tailor your services to each company based upon their needs. Determine pricing and hours prior to providing services, as well as the invoicing method. These cash-based services will assist in protecting your practice’s bottom line, especially at a time when we are constantly fighting for the consumer’s health care dollar. Although some practices have offered services for free to get their foot in the door, I strongly discourage this practice. It is hard to put a price on services when a company is accustomed to receiving them complimentarily.

As rehabilitation professionals, we can be the most valuable resources to companies by implementing effective pre-habilitation programs. When seeking to create business-to-business networking opportunities, remember to look within your own clinic doors first, and do not be alarmed by rejection. Always research a company’s needs prior to meeting with them to show your value. Be willing to tailor cash-based consultation and first-aid services specific to each company. This formula will allow you to become your community’s destination center for industrial rehabilitation, while also securing a strong foundation for your practice’s bottom line.

Larry Briand, MS, PT, ATC, is a PPS member and the founder and chief executive officer of Rehab Management Solutions in Sturtevant, Wisconsin. Larry can be reached at lbriand@rehabmgtsolutions.com.

References:

1. National Safety Council Injury Facts. 2013 Edition. Itasca, IL: National Safety Council; 2013.

2. “RMS Solutions.” RMS Work Injury Program Initiative. Rehab Management Solutions, n.d. Web. 02 May 2013.

3. Mefford, C, Lovett, L. BrandFormation: How to Transform Your Good Healthcare Practice Into a Great Local Brand. USA: Lighthouse Communications; 2010.

How to Do It All

Six ways to work smarter, not harder.

By Sturdy McKee, PT, MPT

Time is the one thing of which we all have the same amount. How we manage our time is up to us.

Without the right tools, many physical therapists become distracted, and they do not accomplish half of that of which they are capable. The average United States worker states that 40 percent of their time is unproductive!

When talking to highly effective people about how they “do it all,” they often discuss a daily six-step praxis. Like me, they have full lives. I am a physical therapist, practice owner, entrepreneur, conference speaker, online advocate of physical therapy, husband, father of three, and community member.

The following six steps for working smarter, not harder, enable me to do it all. They only take about 15 minutes and, in my experience, save two to three hours at the end of the day. I do not know of any other tools that gives me that kind of return.

1. Know Your Big Picture Goals
What do you want to accomplish in the next three months or year? These “big picture” goals should drive your daily activities. Every three months, I sit down in a quiet place and review my long and short term goals. My short term goals must be milestones, which move me closer to my long term goals. I even have this time scheduled regularly on my calendar, so that I do not forget.

2. Brain Dump
Most mornings, I wake up to a brain pumping out a never-ending to do list. Where to start?

I start by sifting through the mental clutter. I write down everything that comes to mind, then I review that list for things I need to keep or discard. If one of the items on that list does not move me closer to my big picture goals, then I dump it. If it does move me towards my goals, but it does not need to be done now, I move to another list that I call the “lockbox,” which is a document where I write down important—but not critical—items.

3. Delegate, delegate, delegate
I then review the items that survive the brain dump and decide if I am the best person to execute them. I can choose to delegate a task or do it myself.

Most people think that if they do not have an assistant, they cannot delegate. I believe delegation only requires consent. Even if the person that I am asking is an employee who reports directly to me, I have to make sure that what I am asking them to do fits within their time constraints and capabilities, and that they are enthusiastic about helping me to complete it on time. Otherwise, I have set us both up for failure.

4. Uncover Your True to Do List for the Day
For the things that I do not delegate, I decide to either do that day or schedule for a later date. For example, if I need to send a group of emails that are not urgent, then I can block the time on my schedule later that day, or at some other appropriate time, to complete that task. I know people respond better to emails on Tuesday morning than on Monday. So, I schedule those to encourage the best response, rather than just having to hurry up and do them now.

After I schedule the “for later” list, I am left with a handful of things that need to get done today. It is a million times more manageable than what was in my head before the brain dump. I prioritize the items so that the most important, urgent or biggest impact items move to the top and get done first. Then I get to work on that list.

5. Deal with the Distractions
As I move through my “for today” list, I try to control any interruptions. I realize that things pop into our heads throughout the day. These interruptions create distractions and can use up some of our attention by trying to make sure we do not forget them.

I keep a “dream catcher,” which enables me to write down these random thoughts and ideas throughout the day so that I do not lose them. I keep this all in an electronic file so I can refer to it the following day when I am doing my brain dump. They then have an opportunity to be recycled.

6. Use Data to Tackle Your To Dos
I first learned about the importance of using data to make decisions from my grandfather. He was a retired United States Army Colonel who, when I was 10 years old, told me that if I did not learn anything else in life I had to learn how to make decisions. Unfortunately, he was not much more specific at that time.

I have since learned that data makes my decision-making better and more efficient. As a practice owner, I am most interested in data about how my clinics are doing. I do not try to collect, sort, and analyze it on my own. In the age of Medicare compliance and health reform, the data is simply too complex and vast. Personally, I use integrated revenue management cycle software made especially for physical therapists that puts the data at my fingertips.

An example of using data to make informed decisions is assessing insurance fee schedules. This topic seems to come up repeatedly. What is your cost per visit? What is your profit goal? The answer to these two questions makes it easy to look at a proffered fee schedule and decide right away whether to accept it at face value. If not, then you now know how to respond to the payer.

Using data also helps us in performance reviews, as every employee has their job accountabilities, core values, and key performance indicators mapped out. Thus, they know exactly how their review is going to go and can reach out if they need help.

By eliminating things that do not lead me toward my goals, delegating what I can, scheduling things to get them out of my brain, and tackling my to do’s with data has allowed me to work more efficiently than I ever have before.

It took me about three months to get into the habit of doing it regularly—that was 10 years ago. I use this process frequently, especially at times when there is getting to be too much to do. Much of it is now habit and is how I approach each and every day and project. It has become part of how I think.

Sturdy McKee, MPT, is the chief executive officer of San Francisco Sport and Spine Physical Therapy. He can be reached at sturdy@sfsspt.com.

References:

1. Survey Finds Workers Average only Three Productive Days a week. Website: www.microsoft.com/en-us/news/press/2005/mar05/03-15threeproductivedayspr.aspx Posted March 15, 2005. Accessed August 2014

Inequitable Fee Schedules

A look at payment changes in New Jersey from the Payment Policy Committee.

By James C. Hall, CPA

Earlier this year, my company, Rehab Management Services, picked up a consulting agreement with a New Jersey–based firm, and I found a payment nugget that is worthy of sharing with every provider in the United States. Before I relay “this nugget,” let me share some insurance basics for those of you who delegate the billing/payment side of your practice to administrative staff. Fifty sets of state and four sets of federal insurance regulations exist. Other than the 50 sets of unique state insurance laws, the federal programs are as follows: