Care Setting Environmental Analysis

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Journal of Hand Therapy 26 (2013) 282e286

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Journal of Hand Therapy

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JHT READ FOR CREDIT ARTICLE #275. Practice Forum

A systems change: Leading the way to meeting health needs

Mirella Deisher OTD, MS, OTR/L, CHT *

St. Luke’s Physical Therapy, Anderson Campus-Hand Therapy, 1700 Riverside Circle, Easton, PA 18045, USA

a r t i c l e i n f o

Article history: Received 2 March 2013 Accepted 3 March 2013 Available online 4 May 2013

Keywords: Program development Leadership Strategic planning SWOT analysis Needs assessment Hand therapy Carpal tunnel syndrome Cubital tunnel syndrome

* Tel.: þ1 484 714 8925. E-mail addresses: [email protected], dm

0894-1130/$ e see front matter � 2013 Hanley & Bel http://dx.doi.org/10.1016/j.jht.2013.03.001

a b s t r a c t

Demonstrating the efficacy of our practice requires a paradigm shift. Becoming an effective leader and clinician can facilitate opportunities for program development and clinical research. The use of strategic planning strategies, such as needs assessment and SWOT analysis, can help lead the way to such change. The following illustrates the use of strategic planning to develop The Carpal and Cubital Tunnel Syndrome Program (CCTSP) within a growing orthopedic practice.

� 2013 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.

In today’s changing healthcare environment, hand therapists find themselves in positions where they need to advocate for themselves and for their patients. This therapist describes her process of utilizing business concepts to implement a new program in her clinic to better serve patientsdVictoria Priganc, Ph.D., OTR, CHT, CLT, Practice Forum Editor.

Carpal tunnel syndrome (CTS) and cubital tunnel syndrome (CuTS) continue to be a primary referral for the hand surgeon. However, as observed within a growing orthopedic practice, the lack of evidence regarding the efficacy of many hand therapy interventions directly impacts referral patterns. To date, the only therapy-related interventions that have been acknowl- edged as efficacious by the American Academy of Orthopedic Surgeons (AAOS) for conservative management of carpal tunnel syndrome are the use of orthotics and low dose ultrasound.1

Consequently, interventions that we have observed to con- tribute to good outcomes, such as activity modification and nerve gliding, are not recognized as being efficacious due to insufficient evidence. Anecdotal evidence is no longer adequate to justify therapy referral; instead referral is appropriately driven by scientific evidence that demonstrates some level of effectiveness.

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Strategic planning: a means to evoke change

Accordingly, it falls upon the hand therapist to lead the way in demonstrating the efficacy of our practice. To facilitate this change, we need a paradigm shift. We must think of ourselves as effective leaders, as well as clinicians. Leaders initiate change within orga- nizations or systems to support identified health needs, as well as clinical research needs. Thus, to create change within our ortho- pedic practice and increase the role of hand therapy in the management of patients with CTS and CuTS, strategic planning strategies were utilized. Namely, a needs assessment and a SWOT analysis were employed to develop The Carpal and Cubital Tunnel Syndrome Program (CCTSP), a program that indicates a one session therapy evaluation and treatment patient satisfaction.

The needs assessment was used to identify health problems that should be addressed in future programs. It served as a starting point for planning, implementing, and evaluating the program, as well as providing information about which interventions were needed and the population to be served. In this case, the needs assessment was utilized to demonstrate how our patients, the hand surgeons, and the organization could benefit from the use of hand therapy in the management of mild to moderate CTS and CuTS.

Based on the AAOS Clinical Practice Guidelines1 for the treat- ment of carpal tunnel syndrome, the only hand therapy interven- tion that was routinely prescribed at this practice for mild CTS was a night orthotic. Patients with CuTS were treated similarly; referred

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Table 1 MATRIX: prioritizing needs for the CCTSP based on importance and changeability

Most important Least important

Most changeable Providing patient education. Screening for rehab needs. High patient satisfaction. Appropriate utilization of conservative treatment (rehab).

Increasing productivity of all staff. Increasing patient volumes. Creating treatment algorithms & internal clinical pathways.

Least changeable Peer buy-in to value EPB and clinical research. Creating buy-in to contribute toward clinical research and outcomes studies. Decreasing patient populations out of work time. Increasing patient adherence to HEP.

Getting the organization to invest in clinical research and outcomes research. Obtaining funding for program development and growth. Obtaining funding for related skill development and education.

M. Deisher / Journal of Hand Therapy 26 (2013) 282e286 283

to formal therapy only on occasion. Thus, the CCTSP program proposed that all patients receive at least one therapy session that would occur immediately after their appointment with the hand surgeon. This visit would include an evaluation to obtain impairment and disability measures, as well as providing one treatment session. The treatment session would include custom orthotics, home exer- cises including tendon and nerve gliding, and education regarding activity modification. At the end of the session, a patient satisfaction score would be obtained using a visual analog scale (VAS).

Likewise, patients scheduled for endoscopic carpal or cubital tunnel release were also typically not referred to therapy. While in most cases therapy was not indicated postoperatively, the CCTSP program proposed that these patients would be evaluated and treated prior to surgery. This preoperative session would provide the same exercises; however, patients would also be instructed on scar and edema management. Additionally, this preoperative session would serve as an opportunity to facilitate appropriate patient expectations with regards to the procedure, the healing process, and their outcomes.

Facilitating realistic and appropriate patient expectations were presented as a potential means to increase patient adherence, satis- faction, and ultimately outcomes.2 The data collected from the hand therapy sessionwould also provide uswith necessary information to assess the effectiveness of the program to achieve these objectives. It was ultimately this factor that unified all involved stakeholders in a decision to move forward with implementing the program.

Table 2 SWOT analysis of current practice environment. The Carpal and Cubital Tunnel Syndrom

Strengths W

� Provider of rehab services of growing orthopedic group. � Funding for on-site continuing education opportunities. � Good management with effective communication systems and procedures. � Interdisciplinary collaboration. � Multiple satellite locations for consumer convenience. � Steady referral stream from orthopedic surgeons. � Marketing funds and support to promote specialized treatment programs. � Orthopedic surgeons that value therapy input and conservative approaches. � Highly skilled staff, most having doctoral degrees and advanced training in

specialty areas. � On-line resources to support and/or advance practice. � High emphasis on patient centeredness and patient satisfaction.

� �

� � � �

�

Opportunities T

� Health care reform legislation signed into law: therapy cap exceptions process, market reforms and coverage of rehab and habilitation included, and protection of OTs scope of practice in prosthetics and orthotics.

� Regular referrals from sources outside of the network. � Provision of services on-site during orthopedic physician office hours with

follow-up provided at satellite clinic. � Partnership with University medical school thus bringing more visibility to the

growing healthcare network. � A teaching hospital provides opportunity to educate residents to the value and

diversity of rehabilitation services. � Growing orthopedic practice with plans to hire two additional hand surgeons. � The company is in the process of expanding, opening new satellites and hiring

additional therapists.

� �

� � � �

�

Implementation of The Carpal and Cubital Tunnel Syndrome Program

In an effort to demonstrate a plan for efficient and effective implementation of the proposed program, thematrix in Table 1was created to prioritize identified needs based on importance and changeability. For example, high patient satisfaction was identified as being both important and changeable to all stakeholders, such as the physicians, hospital administration, therapists, and patients. Therefore, patient satisfaction was a measure the program was designed to improve and assess. Ultimately, all of the components of the needs assessment helpedmake this program defendable, and it helped create “buy-in” from the involved stakeholders.3

In addition to performing a needs assessment, a SWOT analysis was also performed. SWOT is an acronym for Strengths, Weak- nesses, Opportunities, and Threats, and it provides a thorough analysis of an organization’s internal and external environments. The analysis of the internal environment identifies strengths and weaknesses, whereas the analysis of the external environment identifies opportunities and threats.4

The purpose of performing a SWOT analysis from a healthcare provider perspective is to improve the provision of rehabilitation services, increase the consumer base, and improve quality of care, patient outcomes, and patient satisfaction. While these purposes complementeachother, they requiredistinct strategicplanningwhich the SWOT analysis helps to highlight.4 Thus, while the support of the

e Program (CCTSP)

eaknesses

Prolonged delay or lag-time in implementing plans for change or development. Decreased opportunity to regularly collaborate and build relationships with staff due to multiple satellite locations. Decreased intervention time due to productivity requirements. Productivity requirements influencing treatment design. Schedule conflicts to attend all in-services and meetings. Lack of carryover or compliance to home exercises and postural/ergonomic recommendations affecting DASH scores. Minimal role of therapy with carpal and cubital tunnel patients with the excep- tion of orthotics.

hreats

Decreased utilization of services due to high co-pays and weak economy. Acquiring updated equipment and modalities to all satellites for consistent state- of-the-art care. Strict reimbursement guidelines/denial of coverage/audits. Reimbursement limitations based on efficacy studies or lack thereof. Competition of other growing orthopedic groups having their own rehab staff. The effect of increasing costs to small business (healthcare, taxes) on employee benefits and pay. Financial, social and political barriers to support balanced and productive healthcare reform.

Fig. 1. Algorithm: development of The Carpal and Cubital Tunnel Syndrome Program (CCTSP).

M. Deisher / Journal of Hand Therapy 26 (2013) 282e286284

referring hand surgeon was an identified internal strength, therapy productivity requirementsproved tobea ‘weakness’ that needed tobe navigated in order to maintain stakeholder support (see Table 2).

Understandably, hospital administration was concerned about the involved overhead in providing services that would not be billed; providing a billable service was important from their perspective. Conversely, the hand surgeon was concerned about billing for therapy particularly when the patient had minimal impairment. Thus, a consensus needed to be reached regarding what would constitute a billable service. Ultimately, it was agreed that only patients demonstrating impairments that warranted formal therapywould be billed. The evaluationwould be conducted on site and the treatment sessions would occur at the satellite location of their choice. Patients who were provided only a home program would not be billed.

Ultimately, the CCTSP promoted a systems change through three initiatives: 1) the provision of services that had not been routinely prescribed, namely a comprehensive home program for preopera- tive patients as well as those managed conservatively; 2) the implementation and documentation of a systematic protocol, to provide appropriate services to patients with CTS and CuTS seen during physician office visits, as well as to screen for those that would benefit from formal outpatient hand therapy and 3) the analysis and evaluation of the protocol for development of formal outcome studies, such as the utilization of therapy services post operatively and the level of patient satisfaction.

In the end, both the needs assessment and the SWOT provided a roadmap for the successful implementation of The Carpal and

Cubital Tunnel Syndrome Program. The algorithm in Fig. 1 provides a simplified depiction of how these strategic planning techniques facilitated the process.

Results

During a six-week trial period, patient satisfaction scores for 28 preoperative patients averaged 8.7 out of 10 on a visual analog scale (VAS). As a result of implementation of the CCTSP, 15 patients were referred for outpatient therapy services, and 59 other carpal and cubital tunnel patients were given home exercises. One of the most significant outcomes of the program, however, has been the increased involvement of hand therapy to manage this patient population. During this trial period, 20% of patients with one of these two diagnoses were referred to outpatient hand therapy.

Conclusion

Within this orthopedic practice, the success of the CCTSP has shown that demonstrating the efficacy of hand therapy to produce favorable patient satisfaction outcomes directly impacts the utilization of our skills and expertise. Of greater significance, however, it has reinforced that clinicians can facilitate a ‘systems change.’

Stepping into a leadership role and utilizing a systematic approach for program development force us to redefine the tradi- tional role of a clinician. However, the ensuing collaborative process among involved stakeholders can facilitate meeting evolving health

M. Deisher / Journal of Hand Therapy 26 (2013) 282e286 285

needs, support clinical research, and ultimately contribute to the legacy of our evolving profession.

References

1. American Academy of Orthopedic Surgeons. Clinical practice guidelines: treat- ment of carpal tunnel syndrome. J Am Acad Orthop Surg. 2008. http:// www.aaos.org/research/guidelines/guide.asp. Retrieved 10.10.10.

2. Marks M, Herren DB, Vilet Vlieland T, Simmen BR, Angst F, Goldhahn J. Deter- minants of patient satisfaction after orthopedic interventions to the hand: a review of the literature. J Hand Ther. 2011;24(4):303e311.

3. Issel M. Health Program Planning and Evaluation: A Practical, Systematic Approach for Community Health. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2009.

4. Houben G, Lenie K, Vanhoof K. A knowledge-based SWOT analysis system as an instrument for strategic planning in small and medium sized enterprises. Decis Support Syst. 1999;26:125e135.

M. Deisher / Journal of Hand Therapy 26 (2013) 282e286286

JHT Read for Credit Quiz: #275

Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question.

#1. The SWOT analysis advocated by the author is taken from the __________playbook

a. NFL b. Stanford MBA c. Johns Hopkins Medical School d. Ohio State OT School

#2. The only conservative intervention routinely suggested in the AAOS Clinical Practice Guidelines for CTS is

a. US b. nerve gliding c. AROM in the DTM d. resting orthotics

#3. According to the author the typical carpal tunnel or cubital tunnel patient

a. requires numerous therapy sessions post-surgical release b. does not re c. does not require therapy post-surgical release d. does not require a pre-surgical therapy session

#4. The primary problem that the author feels we need to address is

a. the ineffectiveness of our interventions b. lack of evidence to support our interventions c. the close-mindedness of the insurance industry regarding

reimbursement for our interventions d. to improve the leadership course work in our academic

training

#5. The author feels the profession is in need of a paradigm shift to

demonstrate our efficacy

a. true b. false

When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.

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