Workplace Stress in the Rehab Industry and Its Impact on Productivity
5 Steps for Happier, Healthier Clinicians
By Samir Sharma, PT, DPT
Stress is all around us as workers in the health care field.
Whether it is taking time with complex patients, finding free minutes to wrap up never-ending documentation, working on insurance authorizations and billing, declining reimbursements, or try-ing to survive in the age of a global pandemic, stress can be all-consuming and always around us.
No wonder our collective stress levels continue to rise given the ever-demanding health care envi-ronment in which we all work. Each year, there seems to be additional requirements tacked on to our duties involving patient care. Insurance authorizations continue to eat up more of our precious time, billing and coding changes continue to fluctuate on a yearly (if not monthly) basis, and reim-bursement continues to dwindle despite our attempt to prove ourselves as front-line clinicians who have great value and benefit to the general public. In essence, we are getting paid less, all while having to do more behind the scenes. No wonder our teams are more stressed out and get-ting increasingly burned out just trying to keep up!
In a 2013 annual study termed the Medscape Lifestyle Report, 40% of primary care physicians re-ported feeling burnt out.1 When this same report was completed in 2017, that number jumped to 51%.2 Study participants cited an increase in “bureaucratic tasks” (i.e., charting, admin), spending too much time at work, and increasing complexity of computerization (i.e., EMR systems) as the primary contributors for the increase in workplace stress and subsequent burnout.2 And it doesn’t take much to extrapolate that these figures aren’t limited solely to physicians.
Unfortunately, we as practice owners and administrators can’t just wave a magic wand and make all these stress-inducers go away. We have high overhead, bills to pay, and teams of staff to keep afloat despite what may go on behind the scenes. The question remains how we balance running a busi-ness vs. managing and mitigating the effects of stress on our practices and our teams.
Behind our managerial hats, we continuously worry about how to see-saw between maintaining quality patient care, content clinicians, and making sure we have a healthy bottom line. Many health care systems and individual practices around the country have focused on a new metric in recent years: productivity. Vaguely defined, how “productive” an individual clinician is how many open slots a clinician has versus how many are filled with an appointment.
For example, a clinician has 10 open slots in his day for treatment, and nine are taken. This would put the therapist at 90% productive. Of course, there are variables such as evaluations that may count for more percentage points, but this is the essence of the scenario. There are clear guide-lines and expectations when employees are onboarded that they must be at 90% or even 95% dai-ly productivity in many institutions. Some are incentivized beyond this point, and many are issued warnings when they continue to fall below a given threshold. While the initial thinking behind this approach allows for autonomy and practitioner responsibility of their schedule, it has led to a great deal of undue stress on the average clinician. While there is assuredly some benefit to making sure your clinicians self-manage their schedules and stay busy, these objective metrics of performance often stratify clinicians based on quantity and not quality of patient care, inadvertently leading to levels of increased stress.
Starting as a new graduate physical therapist in 2014 and working in a large corporate chain envi-ronment, I quickly found that quality care was not being delivered and quantity over quality was favored. This is the same adage we have heard time and time again in recent years as corporate consolidation floods the health care arena. Starting my practice in early 2015, I was determined to find a way to satisfy both the bottom line and make sure quality care was maintained. When I be-gan, I started as a single owner-operator taking any patient that would come my way. The short game would have been to schedule these precious few patients for as many visits as I could, max-imizing revenue. Instead, I decided to play the long game. I remembered why I ventured out on to my own. I saw patients for just as many visits as necessary, provided extensive value and education to them to give them an understanding of just how powerful physical therapy could be, knowing eventually I would build a strong community reputation and a brand. Six years, two locations, a team of happy clinicians, and thousands of patients later, I can confidently say that the long-game approach of good will, focus on quality rather than excessive productivity, and a stable work-life balance helped to contribute to our group’s success.
Five Principles for Success
There are five foundational principles that I believe can be incorporated into any organization that make our teams as happy and stress free as possible while still ensuring bills are paid and practice owners are happy. Concurrently, I also attribute much of my company’s growth to ensuring content and stable teams who in turn deliver a higher quality of care.
1. Create A Collaborative Atmosphere
A surefire way to create a stressed-out clinician is to make them feel isolated. Let your teams know that we are all working for the same common goals. Remind them you are working as a unit to get our patients better, we are serving a common goal, and we are here to support each other. For my team, this means regular check-ins and lunches with our clinicians to collectively brainstorm a diffi-cult case, a new manual therapy technique learned, and to just vent about any particular ongoings. My team knows they can rely on each other during their day to help manage and troubleshoot any-thing that may come their way. Formulate ways in your practice for your team to be able to com-municate frequently and openly, and lay out time for them be able to do so that is built into their work days. Having them feel connected as parts of a whole will allow a sense of collaboration and teamwork.
2. Provide Adequate Time
According to a recent study in September 2017 from the Annals of Family Medicine, physicians spent more than 51% of their time in a given work day on EMR documentation.3 The same can be said for us in rehabilitation with never-ending evaluations, progress notes, discharges, and physician updates. Structuring your clinician’s workdays and building in time for documentation when possi-ble will allow them to complete their work at the office rather than dragging it home. We all know that feeling of having to open up our laptops in the evenings and finish notes when we’d much ra-ther be spending it our families or other leisure activities. Instead of seeing a gap in a therapist’s schedule as a negative, encourage them to use that to wrap up open documentation. When a par-ticular therapist may be slammed with documentation, encourage partial case load sharing to offset their patient care burden and allow time to finish their work. In our practice, we utilize a PTA who takes on additional patient care at times when our therapists have a backlog of documentation. And, most important, encourage point of service completion for your team to maximize their effi-ciency and reduce/eliminate the burden of take-home documentation.
3. A Focus on Quality
Instead of looking at how “productive” a clinician is in the traditional objective sense, try and high-light the subjective portions of care. How satisfied are your practice’s patients? Are they leaving positive reviews online, referring friends and family members, and coming back for new plans for care? Measure productivity not just in a strict sense of slots filled, but extrapolate other immeas-urable data from members of your team and make sure to provide feedback on a job well done. Making them feel as a part of a whole and contributing will immeasurably remind them of why they do what they do, and even in times of stress, they will remember their role favorably as a valuable part of the organization.
4. Play the Long Game
Just as I described my method to grow my practice, I developed and continue to maintain HR poli-cies that treat members of the team as individuals and people, not just revenue producing entities. Be flexible and understanding when time off is requested, accommodate that to the best of your ability, and be willing to go above and beyond to let them know that they are cared about. When a clinician on our team was expecting a child, we offered him three weeks of paid paternity leave in addition to his earned vacation time. During the pandemic as we ramped up again after being forced to close, our hourly staff was given weekly minimums for hours worked to make sure they felt taken care of during times of uncertainty. When your team feels well cared for, their stress levels and anxiety regarding the job are certain to go down and be minimized. These things may end up costing the practice a little extra financially in the short run, but will assuredly reduce turn-over and training costs in the future as a solid and stable team is built.
5. Encourage Healthy Behaviors
Physical therapists promote physical health and well-being and are certainly known to practice what they preach. But what about our mental health? Managing stress in and out of the workplace is essential in modern life. A 2014 study in The Permanente Journal found a reduction of employee stress, depression, and burnout between 40-94% in its subjects after a four-month practice of tran-scendental meditation.4 Physiologically, meditation has also been shown to reduce sympathetic overstimulation in subjects with regular practice.5 Encourage members of your team to participate in regular stress relieving activities such as meditation, yoga and breathing practice. Last year our team was offered a yearly subscription to the Calm app, which encourages a daily 10-minute medi-tation and reflection, sleep stories to help get to bed on time, and relaxing sounds of nature. Find tangible ways to combat employee stress and actively provide resources for your team to mitigate and reduce its effect.
I find myself a part of many networking groups and collaborate with practice owners from across the country. Many choose to whine, groan, and moan about the adversity we face every day. They complain about stress and its effect on themselves and their teams. I challenge you and your team to do the opposite: remember why you entered this profession, remember how lucky we are to be able to make a malleable change in the lives of our patients, and support your team in your best ability to produce happier, healthier and more stable employees.
1Peckham C. Physician Lifestyles — Linking to Burnout: A Medscape Survey. MedScape. https://www.medscape.com/features/slideshow/lifestyle/2013/public#1. Published March 28, 2013.
2Peckham C. Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout. Med-scape. https://www.medscape.com/features/slideshow/lifestyle/2017/overview. Published January 11, 2017.
3Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: Primary Care Physi-cian Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Ann Fam Med. 2017;15(5):419-426. doi:10.1370/afm.2121.
4Elder C. Effect of Transcendental Meditation on Employee Stress, Depression, and Burn-out: A Randomized Controlled Study. The Permanente Journal. 2014;18(1):18-23.
5Sharma H. Meditation: Process and effects. Ayu. 2015;36(3):233-237.
Samir Sharma, PT, DPT, is an orthopedic physical therapist and principal of Activa Physical Therapy with locations in Southwestern Suburban Chicago. He can be reached at email@example.com