by Ed Dobrzykowski, PT, DPT, ATC, MHS
Productivity: there may be no other topic in the management of physical therapy and rehabilitation services that is more misunderstood and conflicting. How is productivity defined? How does one consider the variability among patients and practice settings? Why is the measurement of productivity needed? How do you benchmark?
As seen in this HPA burning question survey, there are patterns and variability seen. The 171 respondents include practices which may derive productivity data from their billing and financial information management systems, to practices which utilize multiple indicators and deploy methodology unique to their physical therapy practice.
The variability of responses is attributable to differences seen in the five primary areas of PT practice (acute care, skilled nursing, inpatient rehab, home health and outpatient) and patient mix.
BTU (billed treatment unit of 15 minutes) is the metric predominately used (39.2%). This data reflects my own experiences in queries of management class attendees. Visits per day or visits per week may be used in any practice type; I suspect that the majority are home health or outpatient services. The utilization of minutes of service are indicative of skilled nursing or inpatient rehabilitation where the time measurement is crucial to billing in these practice areas and reflective of their payment based patient classification systems. In home health, a combination of metrics is sometimes used, such as a point based system where values are assigned to opening of a case, completing an evaluation and a follow up visit.
The worked hours per unit of service question was unclear and did not permit responses that included decimal points. However, the expected level of productivity for a PT working 8 hours a day as reflected by BTUs averaged 22.76, and for PTAs averaged 21.74. This metric is available in financial software linking billing (units of service) to hours worked (exclusive of paid time off and sick time). Questions 7-8 indicate an outpatient target of 0.4 worked hours per unit of service for practices primarily of patients with musculoskeletal conditions, and slightly higher for practices containing primarily patients with neurologic or pediatric case mix. This is consistent with information that I have seen our own practices and with information sharing by rehab managers.
The expected level of productivity for 48% of respondents was nearly 23 BTUs, which equates to 72% productivity. The minutes of billable service was 67% using a denominator of 450 potential minutes (7.5 hour day); if assuming skilled nursing this level appears low based upon managers’ class surveys noting 80-90% billable time. The visit per day metric is used in home health and inpatient acute services; the visit per week metric is used in home health. The worked hours per unit of service responses are highly variable with a mean that is not interpretable.
The expected level of productivity for PTAs tends to be lower than for PTs, with the exception of CPTs billed and worked hours per unit of service responses which were similar to PTs.
The types of practices, variability in metrics, and results are in line with managers’ reporting in educational classes. In order to manage and improve productivity the following steps are recommended: 1) measure your staff efficiency to create a baseline; 2) set targets for improvements annually for both individual staff and practice; 3) utilize productivity measures in context of and balance with other practice metrics related to quality, patient satisfaction, outcomes, revenue, and expense. Our challenge in management is making improvements that continue to add value to the patient experience while reducing cost over time.
The HPA hopes that the Burning Question, the results from the survey and this blog have provided you with some valuable information on the topic of productivity. For members and non-members, please use this blog as a mechanism to continue the conversation on productivity.
For detailed information on the poll results, please visit the HPA website, where you can view or download the responses in spreadsheet format (members only).
A presentation is planned on this topic by Ed Dobrzykowski, PT, DPT, ATC, MHS at the APTA Combined Sections conference in Chicago on Feb. 9 (sponsored by the Acute Care Section).
Suggested References
- Arslanian L, Gonzales Dean M, Soper S. Productivity Metrics and Outcomes in Acute Care. CSM 2006
- Bohannon R. Productivity among Physical Therapists: An Evaluation of One Department. Phys Ther 1984; 64:1242-1244
- Kovacek, P. Improving Productivity Without Sacrificing Quality Rehab Services. 1994, 1995, Rev. 2011. www.ptmanager.com
- Wiersma, R et al: Rethinking Productivity and Efficiency CSM 2005. PT Magazine, May 2005, p. 54
HPA APTA 
Martha Y. Zimmerman, PT, MA
/ January 13, 2012Boy, I am surprised by the lower precentage of productivity for PTA. I don’t believe that is the trend we see in many of the local SNFs. Very interesting information. I certainly will share with my students. Thanks for allowing me to be in the HPA Section electronic group.
Martha Zimmerman, PT, PTA Program Director,
Caldwell Community College and Technical Institute
Hudson, NC
Brent Healy
/ April 16, 2013I’m an executive with a well known therapy staffing company. We are trying to help our Therapists in SNFs handle these 90%+ productivity requirements. Can any PTs/PTAs please share the data with us so our clients can understand other functional settings?
Hsien Tan
/ April 17, 2013I’m always intrugued by how the number crunchers arrive at productivity expectations. Speaking of an 8 hr day, let’s say 9:00 – 5:00 and a 30 minuts lunch, that’s 7.5 hrs actual work time. If productivity is to be interpreted as billable (units) time, to be 90% productive means 6.75 hrs as billable time; that leaves 45 minutes of each day for all (non-billable) note writing, conferences, bathroom stops, garden variety getting from one patient to the other. If you shadowed that therapist over the course of a week with a stopwatch, I suspect it would be nearly impossible to maintain 90% productivty for any prolonged length of time. Very few payors now pay based on # units billed; rather, they’ll pay contracted flat rates which in the worst case scenario could foster factory like volume at the expense of quality. For Medicare and SNF RUG reimbursements that actually count minutes, a realistic productivity benchmark has to take into consideration non-billable, routine activity that is bound to happen over the course of a day or week.
amyc
/ September 23, 2013I am a PTA I have just joined the world of PRN and most of my work is at SNF’s. we have an 88% productivity rate from the SNF and 85% from PRN company. It’s not possible..period. I arrive at new facility get a quick orientation and print off or stack of files of patients I will see. In order to give these patients any kind of quality care I must review their files and previous 2-3 days of treatment. then I have to hunt them down..most of the time the room numbers are not correct, there is no set or even hoped for schedule for PT or any other interactions ..except lunch which can be in room or dinning room from 11-1. There is no time for getting to the room transfer pt. to a gym if needed, no time allotted for documentation..which is required for getting paid not to mention is essential for truly effective care across staff, no consideration for convincing the patient they need to do therapy despite being tired, in pain, cranky, just got into bed, don’t feel like it, dementia, disorientation, family members in the room and in the way and well SICK! If I want that golden number of 88% I have to work documentation time into the treatment ..how do you do that when you have a CGA pt?? or you have the rest and recover at the end of the ex. for 10 mins while you crank out some generic note on a slow as molasses computer system, you find creative ways to bill them for exercising on the way to the gym, ..oh and forget bathroom breaks or that forgotten LEGALLY required 15×2 break plus and actual 30 min lunch ..NOT documentation time, which it is usually used for.cause well we gotta meet that silly quota number. So who looses here? …The patient and the employee that’s who. How about having an actual manager that helps monitor how employees actually DO THEIR JOB..which sometimes means finding your patient, talking them into just getting out of bed and listening to them ..letting them know we care and yes we want them to get better and get the heck outta here!!! It’s absurd, we all ,more than likely, got into this profession because we love people and want to help them get healthier. I spend so much of my day trying to figure out how my numbers are stacking up for the day ..it stresses me out more than the agitated, ornery old man taking a swing at me because , well he’s tired and frustrated and no one takes the time to just actually LISTEN to him .. sorry sir, we are too busy to stop to help you..you just need to get up and do these few things so I can hurry out and get to the next number…um, I mean patient. Insurance/Medicare sucks…. Rehab and nurses rock.
sara
/ October 23, 2013amyc, WOW you just said exactly what I have experienced in the last 3 weeks of working at a SNF LTC facility. I just graduated and this is my first job. What a shock for me to realize that the only way I could meet 100% productivity was to stay an extra hour min to do my documentation and an extra 2-3 hours to do it if I happen to have 3-4 progress notes to do. I see others shaving tx time off to accumulate docum time and doing it at lunch (during the daily meeting, so they are half listening) or at end of day when they have no pts because they crammed them all in before 3pm by cotreating and working w 2-3 at a time. Many times pts sit doing nothing as the therapist works with someone else. I see pt’s get upset at the time they are wasting and at the lack of attn.
I don’t know how long I can stand this on my conscience. There are endless inservices and meetings as well as the big 1x week mtg where pt.s are discussed and how we can minutes up (most of this I don’t understand but it seems not right) or trying for ULTRA’s or running pt’s down…- it just seems care is not centered around pt needs but on the administrations bottom line and productivity. .
You hit the nail on the head w SNF’s as far as the obstacles encountered when retrieving pt’s and trying to motivate them to come to therapy, then once they have been convinced to come they need to use the bathroom during tx or you find out they are soiled and have been sitting in it for hours prior to them coming down. Another issue: they haven’t been given pain meds and nurses seem to not be found when pt is a Max-A x2 transfer and still in bed in gown at 9am… many pts have dementia or other co-morbidities which make PT more complex and time consuming to complete activities. At our place they have Restorative care for once pt is done w PT. This is unskilled exercise but they take pt’s who are in therapy and then we go to get them and the pt thinks they already had therapy and refuses to come! This is a continual problem and I suppose not common to all SNF’s. It just seems to me there is no cooperation between departments and there are even attitudes hindering pt care that form between nursing and therapy at many facilities. They should focus on team work more than worrying about productivity. The CNA’s and nurses I assume are run ragged and probably burnt out w documentation as we are I assume, I wonder if inpatient care in a hospital would be a better environment? Does anyone know which setting is less focused on productivity and more on pt care… SNF’s pay more but I can see getting burnt out after a year of this and I don’t know how long I can play their game, I do have a conscience and I truly care for my pt’s, they know when I work with them I am focused on them and not distracted other places. I carry a sm pocket notebook and jot down imp points and activities completed so I can remember what occurred when documenting later. Because of this I am the least productive employee and proud of it!
Sara
Lisa
/ February 8, 2014I am at a loss that the APTA doesn’t stop the crazy productivity standards that rehab companies are forcing onto their therapists. I was recently threatened to be written up each time I did not meet that standard and 3 of those equal termination. There is no way therapists are achieving 80-90% billable time consistently each day while still billing ethically and only for skilled service. The APTA needs to put a stop to this so therapists are able to give high quality care and bill for skilled service without threats of loosing their job.
Karen
/ February 13, 2014Sara, sounds like a lot of things at your place of work are not even legal. Concurrent tx and restorative therapy while on service of PT? That doesn’t sound right. Ach place is different as is each setting. Try inpatient rehab as the criteria is specific. Patient there have to perform at least 3 hours of hterapy a day 5 out of 7 days(although industry statndard in most places offers therapy a 6th day). This is usually combined with OT and speech if the patient needs it. Usually you work with the patient 1.5 hours each day, one on one. I hated working SNF because of that productivity standard and I felt it very unethical. In a perfect world, yes, it would be great, but to those in the trenches, 9 months of that was all I could take. I love inpatient rehab.
sara
/ February 17, 2014Lisa and Karen, is there anything that the APTA can or will do… I think that is a great avenue to get real industry changes, maybe even contacting senators… I am giving ethical care as I am one of the only one that stays 2 hours past clock out time to handle my daily notes and weekly progress notes. Your right though I am beyond burnt out! I love the patients but I am exhausted and my family time has been cut as I get home at 6, 7, or even 8pm some nights. 100% productive is a nightmare… Does medicare know or have a way to know if a therapy company is doing or making their team be 100% productive? are the SNF’s demanding higher productivity or is it the therapy companies trying to make more profit off the SNF’s by demanding their therapist be 100%?
Sarah
/ April 30, 2014now we can’t put weekly progress note done this day on our daily note because they said they might assume we are billing for the time it took…. Ok so who is paying me for the time it takes to do 7-10 weekly progress notes a week?? I should just donate that time because it is not billable..I am staying 1-2 hours over my clock out time to get my daily notes and tons of progress notes done. Only way to go quicker with 100% productivity is to not be careful and accurate in what I am writing. Takes longer also because we have no control over our pt schedule from day to day it changes. I may see a pt one time only for their progress note day.. then not see them again for another 2 weeks.. How does one establish good pt care and have continuity of care when the juggling of minutes is more improtant than keeping pt’s with the same therapist from day to day. Very frustrating for therapist and most pt’s. Also minutes from day to day are different. one day 72 min, next 37, then 56, then 92, then 17… seriously I had 15 min w a pt I never saw before and their weekly progress note was due… Are all SNF’s like this??
Sara
/ April 30, 2014Karen: correction when I said they take pt up to restorative when they are on therapy I meant they take them up to activities in the restorative gym and do exercises with them as a group. This makes them think they had therapy though LOL! It is hard to get them down after they went up there : ).. They get Restorative care after therapy is d/c… I mixed up the lingo in my above comment.
J----n
/ June 28, 2014Everything Sara said is accurate for me also. As a PTA I have worked at 2 of the larger SNF companies…and in multiple buildings to cover for these companies-they are all the same. 90%+ productivity demand, managers demanding covertly that therapists should clock out and do paperwork to maintain productivity #’s, managers telling therapists ” everything is billable” ( checking charts, progress notes should be done during tx, talking to family or nursing, transporting pt, waiting for them to toilet..etc, etc.)
The management threatens termination or writing people up if they don’t meet productivity. I see therapists co-treating but billing individually, 3 or 4 pt’s sitting around with ankle weights, on estim and the omnicycles–all “working” with the same therapist…I am so exhausted-mentally, physically and spiritually..where is the APTA !!!???
Dana
/ July 22, 2014The APTA announced they are getting involved in this fight. I was just reading it in an announcement this week. Of course, they cannot come to work with us or demand our employers follow the law. WE have to be the ones to do that. PLEASE do not let yourself be bullied into breaking the law. Working off the clock is against the law. Over billing is against the law. Billing for skilled services when they are not skilled is against the law. Your employer will say they had no idea if you get caught. 100% productivity is mathematically IMPOSSIBLE! Either let them fire you and take them to court, leave for a better place or report them to your patient ombudsman. That will require an investigation and you can be anonymous. Overbilling patients can be investigated. PLEASE stick together and support each other. Otherwise our entire profession and our patients will suffer. THANK YOU for voicing your concerns here.
Sara
/ August 4, 2014Do you have the link to the APTA’s announcement.
This is a big fight and I am afraid the productivity standards are inching higher at all places these days.