This is Part II of a two-part mini series on ethics in OT practice. This post discusses productivity requirements and how they impact practice for OTs and other rehabilitation professionals both in and out of the workplace. Click here to read Part I, about my experiences with ethics as a FWII student.
In my current vocational rehabilitation (VR) fieldwork setting, the VR counselors and others have productivity standards measured by how many cases they successfully close, which is typically defined as clients becoming employed. Although right now I am working in a non-traditional setting, there is a much larger discussion taking place about ethics as they relate to productivity standards in the rehabilitation and skilled nursing facility (SNF) settings where a large percentage of OT/As work. The argument being made by professionals in several different fields, including PT, OT, and SLP, is that the extremely high productivity standards to which they are being held takes an extremely negative toll on the quality of care they are able to provide, as well as placing them in ethically compromising situations.
The ongoing issue of productivity as it relates to ethics sheds some light on a grim reality of occupational therapy practice that students, new grads, and others may not be aware of as they enter the profession and begin practicing. After my initial FWI experiences in a large teaching hospital and outpatient pediatric clinic last fall, I became very aware of the pressure put on therapists to see 8-10 patients – and complete documentation, attend meetings, and coordinate case services – during the workday in order to meet unrealistic standards of 75-90% productivity.
It was a sad reality check, seeing the “dark side” of the fun sessions and client interactions I observed that initially drew me to OT. However, now that I have been in OT school for over a year and seen all sides of the therapy process, I’m coming to realize that it’s not all sunshine and successful sessions.
Even in the VR setting the productivity standards seem impossibly high at times. For example, VR counselors and others typically have a goal of 80% closure (successful employment outcomes) for all the clients they see. Counselors can get 5-12 new clients every week, and they must complete the initial interview/intake, documentation, filing, and paperwork for each person. In the one month that I’ve been at VR, I have developed a caseload of over 20 people that I have to keep in contact with, complete paperwork for, provide direct intervention to, and monitor on an ongoing basis. This doesn’t even include the work other counselors and I do calling and meeting with clients, scheduling appointments, writing notes, meeting with supervisors, and participating in other events like group education sessions or mandatory conferences both in and out of the office.
All of this work toward an 80% closure rate is further complicated by the fact that many clients fail to appear for appointments, do not complete the necessary paperwork in a timely manner, fail to follow the steps necessary to achieve a successful employment outcome, or simply lose contact with the agency, meaning that their cases must be closed unsuccessfully.
This same struggle to meet productivity standards takes place in many other practice settings as well. In traditional rehab and SNF settings, productivity is typically defined as the number of clients or amount of services a clinician must see or provide within a certain period of time, like each day or each month. The issue of ethics arises as clinicians are required to see a very high number of clients to meet productivity standards that do not take into account all of the other work that they must do as part of their jobs. For example, OT/As have violated ethical principles in an effort to meet productivity standards by:
- Committing insurance fraud by billing for clients they did not see
- “Double booking” clients and seeing two people at a time
- Providing services to clients that are not medically necessary (especially in SNFs)
- Documenting services inaccurately to meet productivity standards
- Utilizing OTA services without appropriate supervision
- Providing OTA services beyond the OTA scope of practice
This is a very important issue within rehabilitation professions, and many individuals and organizations have spoken out about it at local, state, and national levels. For example, individual bloggers have described the pressure they face in the workplace to see a certain number of clients and several professional organizations have joined forces to release statements on the matter (see Resources below). Although these efforts are helping improve the current situation, there is still a long way to go before clients and clinicians are fully protected from the harmful outcomes that can result from such unrealistically high productivity standards.
There are several ways you can protect yourself from entering unethical situations, including:
- Being familiar with the OT Code of Ethics
- Being aware of the boundaries of your role as an OT student, OT practitioner, or OTA
- Asking potential employers (and potential coworkers) interview questions that get at their workplace’s productivity requirements
- Doing research on potential employers to learn about standard company practices
- Understanding practice guidelines and expectations in your specific setting
- Making well-informed decisions about where to work
- Communicating openly and honestly with supervisors in your school or workplace about your capabilities and how they fit (or not) with workplace requirements
- Understanding the law as it relates to your practice setting (i.e. Medicare, IDEA, etc.)
In the future, I’m hopeful that through continued advocacy by OT and other practitioners, professional associations, and supporters, we can start moving towards positive change for clinicians and clients who are being negatively impacted as a result of these sky-high productivity standards. Change won’t happen overnight, but by being vocal about our professional needs and limitations and the value of clinical judgment in providing skilled services, I believe that the OT profession and others can continue developing a healthcare environment in which these kind of ethical challenges and violations are the exception, and not the norm.
NOTE: If you are ever in a situation where you feel as if you are being pressured to commit fraud or practice unethically, you should document the incident(s) as clearly as possible, communicate with a manager/supervisor about the issue, and attempt to remove yourself from the situation as soon as possible if you are not able to resolve it. Other options include filing a complaint or reporting fraud, although these decisions should be made according to your best judgment and with sound advice from a trusted mentor or lawyer.
For more information on how to avoid making unethical decisions or committing fraud, consult with your program advisors (if you are a student), or state or national occupational therapy associations.
The links below provide more information about student and practitioner experiences with ethics, how productivity standards affect OT practice, and how other practitioners have handled challenges related to ethics and productivity.
- This AOTA document is an Advisory Opinion for the Ethics Commission that outlines “Ethical Considerations for Productivity, Billing, and Reimbursement.” It provides an example case study and discussion about how similar situations should best be handled, as well as clearly outlining the ways in which making false billing claims or providing unnecessary services violates the OT Code of Ethics.
- This is a lengthy but enlightening article on the APTA’s PT in Motion blog that discusses the productivity challenges many therapists face and gives several tips on improving productivity for practitioners who are struggling to meet workplace demands.
- AOTA, APTA, and ASHA collaborated on a “Consensus Statement on Clinical Judgment in Health Care Settings” that “provides examples of unacceptable practices and reminders on the importance of knowing all rules and regulations, following proper evaluation and treatment protocols, and completing all documentation.” It also “encourages clinicians to take action if they encounter a billing process that may be suspect and are provided with possible steps to take in response to employer policies or practices that conflict with clinical judgment.”
- The ASHA Leader professional publication had a great article about productivity and ethics in skilled nursing settings.
- Read the Wall Street Journal article that helped thrust the issue of ethical therapy practice and overbilling in nursing homes into the national spotlight earlier this year.
- This journal article gives a great review of ethical challenges faced by OT students. Although the author makes it a point to say that overall students observe ethical behaviors during fieldwork, there are many situations in which they, like me, were conflicted about other things they observed.
- This is a truly revealing blog post by an experienced PTA who describes her frustration with the impossible demands of the SNF she works in and how it impacts the quality of care she provides. It’s summed up nicely in this quote:
“A therapist’s worth to a company has been diminished to a ridiculously high percentage of billable minutes. It seems we are asked to adopt an invisible, yet very real mission statement that reads, ‘I will do my best to meet the very high standard of productivity by giving mediocre care, ineffective communication and ignoring the needs of those around me as I understand that the most important aspect of my job is to facilitate revenue for the facility. If required, I will compromise my personal integrity, family time and compassion for myself and others to make sure this level of service becomes the standard until the whole system self-implodes.’”
- Chris Alterio at ABC Therapeutics wrote a brief post about the ethical challenges OT students face during fieldworks in SNFs, and why they feel like they cannot challenge the status quo. He also provides information about the “discovery” that many healthcare companies are taking advantage of Medicare payment systems (and therapists) to increase revenue with little benefit to clients or clinicians.
- Many OT/A practitioners are feeling pressure from employers and major rehab companies to see more clients in less time (and often for less money), and the engaging discussion on this topic at the AOTA Checking the Pulse blog is definitely worth the read.
- Rachel Wynn, the SLP author at Gray Matter Therapy, provides a fascinating mathematical breakdown of how a therapist’s salary, caseload, and productivity standards interact to determine whether or not productivity requirements are being met. And then she follows it up with a closer look at what a therapist’s daily schedule would have to look like at 90% productivity (Spoiler: IT WOULD LOOK INSANE).
- This post is from a new OT grad who started working in a clinic where she was being asked to do several unethical things in order to meet workplace productivity standards and follow company rules. The comments offer useful perspectives on how to best handle this situation and others’ experiences in similar situations.