The Tao of patient-centered care

“Tao (pronounced “dao”) means literally “the path” or “the way.” It is a universal principle that underlies everything from the creation of galaxies to the interaction of human beings. The workings of Tao are vast and often beyond human logic. In order to understand Tao, reasoning alone will not suffice. One must also apply intuition.” — Derek Lin

Patient-centered care (aka client-centered care, patient-directed care, patient-driven care, etc.) has infused the published descriptions of today’s healthcare industry and professions.  National and world health organizations include patient-centered care as a hallmark of best practice. A casual medical database search of this term immediately yields articles in journals of nursing, dentistry, medical devices, surgery, social work, hand therapy, health management, primary medicine, behavioral medicine, rehabilitation, emergency medicine, mental health, occupational therapy, and many more.

Yet, according to the same body of literature and my own observations, truly patient-centered care remains largely unpracticed. It consists of attitudes and actions that can be a challenge to live up to, an ideal to be ever sought and only attained through practice and diligence.

True story:  A 17-year-old girl was admitted to a hospital psychiatric unit with terrifying hallucinations and delusions. She wept copiously and had not slept for days. She continuously prayed aloud or ruminated about having brought the Zika virus into the world. Her parents, immigrants from South America, were distraught, and asked to have their priest perform a rite of exorcism as soon as possible. The patient and parents were counseled about the neurobiological nature of schizophrenia and importance of medication, but remained firm in their request. The psychiatrist and team made this possible by providing a private area for the ceremony to take place, and interacting with all involved […]

Our productivity is based on patients, not the bottom line

“Productivity — the amount of output delivered per hour of work in the economy — is often viewed as the engine of progress in modern capitalist economies. Output is everything. Time is money. The quest for increased productivity occupies reams of academic literature and haunts the waking hours of C.E.O.s and finance ministers.”  – Tim Jackson, ecological economist and professor of sustainable development at the University of Surrey

I am an occupational therapist and six years ago I also became a small business owner. My parents were hard-working entrepreneurs, so I had lots of early exposure to the ways of business. Our dinner table conversations often included discussions about bills of lading, sales reports, delivery dates and inventory. I learned the essential nature of a sustainable business: more money coming in than going out.

I understand that healthcare is an industry. Whether the hospital, outpatient clinic, rehabilitation center, skilled nursing facility or home health agency is set up as a not-for-profit or as a traditional business, if it runs at a deficit it is unwell and ultimately unsustainable.

In my parents’ business the main measure of success was selling goods at a profitable rate, while maintaining low-as-possible overhead costs. Each quarter they would hope to do a little better than the one before. Some years were better than others, but over time they became skilled at figuring out how many lawn mowers or hedge clippers to order, and ways to keep their employees productive even in the Midwestern winter (answer: sell snow shovels and Christmas trees instead of lawn equipment).

Healthcare professionals typically view our main measure of success as the degree to which we help those we serve. The organizations we work for usually highlight patient care in […]

 Interprofessional healthcare is a big deal

The World Health Organization has been pushing interprofessional healthcare delivery for more than 50 years, and is not alone. Almost every major professional association has endorsed IP team approaches, including the American Nurses Association, American Speech and Hearing Association, American Occupational Therapy Association, American Physical Therapy Association, American Academy of Physician’s Assistants and American Academy of Family Physicians.

In the past 10-15 years many universities have developed courses or curricula to infuse interprofessional practice into entry-level medical, nursing and allied health education. The young practitioners coming out of these programs are better prepared than ever before to engage in interprofessional teams, given the opportunity.

If you were educated prior to 2010, you may be confused by the relatively new emphasis on interprofessional teamwork in healthcare. Patients pretty much everywhere receive care from an array of different professionals within each setting, so you may think that a bunch of care providers all working alongside one another equals an interprofessional team. Not so.

What is this unicorn of healthcare delivery? Authentic IP teamwork looks like this:

There is an IP Plan of Care for each patient that is negotiated and decided by the team.
Roles of care providers are fluid and determined by the patient’s current key needs.
Team members are both experts in their disciplines and knowledgeable about others’ skills and roles.
Everyday work is coordinated and often shared.
Communication is regular and frequent.

“…you may think that a bunch of care providers all working alongside one another equals an interprofessional team. Not so.”
If your everyday work experience resembles this model, you are lucky! Despite universal agreement regarding the desirability and effectiveness of IP practice, the majority of clinical practitioners have yet to achieve this ideal.

There’s a growing body of […]

My views on the ‘McDonaldization of medicine’

E. Ray Dorsey, MD, and George Ritzer, PhD, published a Viewpoint article in JAMA Neurology a year ago that has repeatedly resonated with me. These writers — a neurologist and a sociologist — recognize healthcare can be delivered in an individualized way, given the right conditions.

The writers describe how fast-food management principles have been applied to healthcare and the results of using this style. Four qualities define the McDonaldization of medicine, and each has its benefits and costs. Here is my interpretation of Dorsey and Ritzer’s table, depicting the effects of the fast-food approach on therapy services and therapists.

Dimension – Efficiency

Presentation – Use brief sessions and pre-set frequency/duration of treatment.  Use questionnaires rather than observations. Focus on productivity standards. Provide fewer OTs and OTAs to produce more billable units.

Benefit – More patients are processed at a lower cost.

Cost – Patients receive decreased client-centered and holistic care, reduced interpersonal rapport and suboptimal outcomes. Therapists experience burnout.

Dimension – Calculabilty

Presentation – Count and record actions and easily measured outcomes. Evaluation, intervention and outcomes are measured numerically.

Benefit – Data can guide future practice and research.

Cost – Practitioners’ attention and time is diverted to recording data. Reduces care to small, discreet values, losing the big picture view.

Dimension – Predictability

Presentation- Utilize protocols, checklists and templates, plus scripted interviews.

Benefit – Ensures attention to a standardized set of critical factors and actions.

Cost – Can result in rote, automatic care that ignores unique needs and client motivations. Can obstruct building therapeutic relationship. Clinical judgment and creativity are stifled.

Dimension – Control by nonhuman technology

Presentation – Use electronic medical records that dictate clinical reasoning, billing codes and utilization review.

Benefit – Provides systematic, easy storage and sharing of information for patient care, program evaluation and research. Can ensure […]

By |February 1st, 2017|Categories: From the Editor|Tags: |0 Comments

Break away from behavioral modeling and dare to be different

“Be the change you want to see in the world” – Mahatma Gandhi

Some years ago my mother, sisters and I traveled to London together. It was my first transcontinental flight, and I was excited and a bit nervous. As I sat next to my older sister, I saw her remove her shoes and put on some little sock slippers. I took off my shoes and put on slippers, too. Soon after, she reclined her seat; I did the same. When asked if she wanted a beverage, she ordered green tea. I also ordered green tea, but soon regretted my decision. You see, I truly hated green tea!

Why on earth did I, a grown and very independent woman, imitate my sister even to the point of ordering (and yes, choking down) a beverage that tasted like grass? I had to laugh at myself, even as I sipped the nasty stuff. Once a kid sister, always a kid sister, I guess.

If you recall your psychology courses (social learning theory), you know that it was more than just family dynamics; it was behavioral modeling. The hard-wired tendency to unconsciously copy one another is arguably the foundation for all human bonding, grouping and the evolution of cultures.

The things we do and the choices we make every day are influenced by many unconscious perceptions. Going with the flow is great for keeping harmony and ease. However, it becomes a problem when we sacrifice things we value such as integrity, originality, improved performance — or a good beverage, for example. Unless we deliberately elect to stay attentive and course-correct as needed, we probably end up navigating our days on imitative auto-pilot.

I sense that behavioral modeling is one of the reasons that […]

By |December 23rd, 2016|Categories: From the Editor|Tags: |10 Comments

My vision for an OT practitioner’s Bill of Rights

Writing is one of my coping strategies. One year ago, I got fed-up-to-here with pain-filled stories of suffering and injustice among my colleagues, so I responded by drafting a list of “Basic Rights for Healthcare Professionals.” Then I proceeded to record a pretty awful video of myself talking about them. I brought the video back out today as a kind of private anniversary moment, and it was painful to watch.

I was in my backyard and my neighbor was using a deafening chainsaw, but I was too stubborn to just hang it up for the day. I had to laugh at myself and was glad that not too many people had viewed it.

Despite its technically flawed delivery, I remain passionate about the Bill of Rights idea, and I still want your feedback. This time I’ll just let you read it and skip the video with the chainsaw soundtrack.

Basic Rights of OT Practitioners (a work in progress)

All certified/licensed occupational therapy practitioners deserve to be treated with respect and to practice with the autonomy conferred by our accrediting agencies and licensing boards. They have the right and responsibility to routinely and consistently:

1) Follow the standards of practice and codes of ethics of our profession.

2)  Follow state and federal laws, such as those that mandate reporting suspected abuse and neglect of vulnerable clients, including fraudulent practices or documentation of services.

3) Work in conditions that routinely support basic physiological needs (i.e. flexible time to eat and use the restroom).

4) Be paid for their professional services, including documentation, evaluation interpretation and reporting, communicating with team members on behalf of the clients, and treatment planning.

5) Make clinical decisions in the service of their clients based on their professional expertise and reasoning, […]

By |November 9th, 2016|Categories: From the Editor|Tags: |2 Comments

Permission to speak freely

Occupational therapists and assistants are more than my colleagues. They are my former students from the classroom, fieldwork and internships. They are passionate about our profession. They are my co-learners at professional conferences. Today they are my readers, and people whose words I may read one day. They are my pals and partners in crime, as we’ve invented the just-right challenge therapy group or a lab activity. They are the people I can call on at a moment’s notice and who have always responded with hands-on help, words of encouragement and ideas for how to get things done. They are my role models — the people I never want to disappoint or let down. I see them as compassionate, smart, hardworking and generous to the point of giving until it hurts. I love them all.

I really want to write blogs that inspire and energize OT and OTAs. The rub is that I know how very difficult practicing real occupational therapy can be right now.

For years, I have been hearing from therapists all over the country and in many different practice settings (SNFs, acute care hospitals, rehabilitation centers, public schools and non-profit agencies, to name a few). They have been warned against providing any services short of or beyond what has been predetermined as billable. Many are threatened with sanctions or termination if they are caught documenting after-work hours, although there are not enough minutes allotted in the day for this. The very notion of providing client-centered, occupationally-focused and holistic care is frustrating and foolish, in these workers’ worlds.

I have witnessed the acculturation of my students to this reality, when they would come to my classrooms after their Level I fieldwork experiences looking confused and […]

By |September 22nd, 2016|Categories: From the Editor, Uncategorized|Tags: |12 Comments

Come to the table: Key reasons to join in decision-making

Recently, I read a compelling Facebook post by Brent Braveman, PhD, OTR/L, in which he wrote: “In another thread on a state association’s Facebook page I suggested that in order to be successful in responding to bundled payments by CMS, we need to have a seat at the table and understand the conversation. A colleague responded by describing my words as ‘trite and overused.’ So I provided 10 examples of ways my staff and I have found a seat at the table to promote the distinct value of OT.”

Braveman proceeded to list 10 excellent examples of ways that he and his staff have used or created opportunities to be included in decision-making groups within their hospital system. These committees included falls prevention, procuring DME and hospital safety. They make decisions that hugely affect patient care and therapists’ everyday work lives. I applaud Braveman’s active participation, encouragement of his team’s involvement, and willingness to take time to endorse and explain why taking a seat at the table is necessary and good.

No matter where you work, whether in a large and complex system or a solo practice, there are small groups of people making big decisions that will affect your everyday work performance and quality of life. Whether informed or uninformed, these people open and close the doors to your ability to practice occupational therapy fully and your quality of life on the job. If they do not have an assertive occupational therapist in the group, your perspective will be absent. Let’s be real. Who else on the team thinks as you do? Can you count on other professionals to look at patients’ needs with the breadth and depth that you have, or to look out […]

By |August 30th, 2016|Categories: From the Editor|Tags: |1 Comment

Good things come in small packages: Starting a private practice

Judging by comments from our readers, many of you have great, innovative ideas that you cannot always use in traditional workplaces. There are three ways to gain increased control of your practice:

1) Locate and get hired by a facility that honors your expertise and supports the kind of OT you want to provide. Fabulous, when it works!

2) Overcome resistance and gradually infuse great OT practices into settings that did not previously have them.

3) Start your own independent practice and control the quality and nature of your services.

Before you get the vapors and generate 500 reasons why you cannot start a private practice, let me just say that it’s OK to start very small and to take your time. Actually, that’s best. Also, it does not have to be all or nothing. In fact, giving up your day job one day to jump into a small business the next is not generally ideal.

Small is wonderful. Slow is fine. Part time is beautiful, too.

Not pursuing the career that you truly want and love is neither wonderful nor fine. Not fully developing your unique translation of authentic occupational therapy is a tragic loss for yourself and the many people who would have benefitted from your service.

Occupational therapists and occupational therapy assistants are well-positioned to be successful entrepreneurs. We offer services that are unique and valuable. We can craft novel and effective solutions to real-life problems. We are passionate about our work and emotionally connected to those we serve. Our clientele can access our services directly, without needing a physician’s referral.

If you’re intrigued by the idea of working with a few private clients, here are some initial baby steps to get you started:

• Read about OT practitioners who […]

By |July 28th, 2016|Categories: From the Editor|Tags: |3 Comments

A little bit of effort can have a huge impact

For several years I was the occupational therapist at a residential treatment facility for children with severe mental health problems. Initially I was hired to provide school OT services for students with fine motor/handwriting goals. Clearly, these children had problems beyond poor handwriting. In fact, they were referred to as the “sickest kids in the state” by some of the staff and administrators. I eventually initiated a number of OT programs at the center, but the after-school OT activity program was my favorite due to its simplicity and amazing impact.

I was the school OT for at least a year when I started asking to expand into the residential units. Initially I hit strong resistance because there was no budget even though I offered to staff it with OT and OTA fieldwork students. We also were told it wouldn’t be safe, even though we all passed  crisis prevention and intervention classes. In addition, we were told the child-care staff would feel intruded upon, even though it turned out they wanted us. After months of persistent effort we were allowed to observe in the units and offer ideas. What we saw was very sad.

Although the center’s newly built living spaces were clean and bright, life in the units was occupationally sparse and monotonous. The children spent a lot of their after-school and evening hours waiting — waiting for dinner, waiting to take a shower, waiting for a turn at the video games. Time was largely spent quietly in their rooms or in front of the TV, with bursts of excitement when behavior escalated into arguments, tantrums or fights. No wonder they had incidents of misbehavior and aggression. Boredom is painful, especially when there’s no end in […]

By |July 1st, 2016|Categories: From the Editor|Tags: |7 Comments