Episode 42: Creating a Positive Patient Experience

AD: Alliance Physical Therapy partners in Agile Virtual Physical Therapy proudly present Agile and Me, a Physical Therapy Leadership podcast devised to help emerging and experienced therapy leaders learn more about various topics relevant to outpatient therapy services.

Richard: Welcome back to Agile and Me, a Physical Therapy Leadership Podcast series. Today's guest is Joanna Bailey. I'm really excited to speak to joanna has been a patient for physical therapy, I think more than a couple of times, and I'm excited to talk about the patient experience, the patient journey. So welcome, Joanna. Thank you so much for being on this episode.

Joanna: Thank you for inviting me. I love to talk about my experiences.

Richard: That's great. What I found most interesting was the fact that even though you've been a consumer of healthcare, like a lot of people, but consumer of physical therapy, you actually have a significant experience within the healthcare space yourself, don't you? So I'd love it if you perhaps told the listeners a little bit about your background because I think this will really shape our conversation as we talk about the patient experience.

Joanna: I've worked in healthcare for the better part of 30 years, and I've done so as a minister, as a hospital chaplain, and that has allowed me to participate in a lot of interdisciplinary conversations with members of rehabilitation staff over the course of pediatric as well as adult work. And so I've read a lot of chart notes, I know what physical therapists are listening for in their assessments. And one of my favorite responses to one of my assessment pieces that I filled out prior to receiving care at another physical therapy company was, wow, that's really helpful. Wow, you really knew what we needed to know. And I just laughed and said, yeah, I know enough to be dangerous within the physical therapy world.

Richard: That's great. I'm sure you've undoubtedly, in your years of experience, come across very good and also, unfortunately, probably some bad experiences. It pertains to the patient experience. So it'll be interesting to talk perhaps a little bit more broader as well. The other thing I would mention, I think, is physical therapists or rehabilitation experts, licensed rehab personnel, be that Ptot speech, I think we're in a really fortunate and lucky position because we get to spend a lot of time with patients, more so than, I would say, most other healthcare providers. And I think that really helps, doesn't it, with regards to truly connecting with patients? Is that your experience?

Joanna: Yes, it is. And there is a physical connection, obviously, because the therapist has hands on your body and they are talking with you and you are hopefully speaking to them as well. And in one experience with a therapist, in the midst of my treatment, I learned I was going to have to have a hip replaced. And I showed up at the next therapy appointment and just broke in down in tears and got pulled into a room, and the door closed and kind of cared for at that moment. But because that therapist had been through that journey with me, she could use the knowledge of me to support me and help me to get to kind of the next phase of what I needed to do.

Richard: Yeah, I think a lot of healthcare practitioners, certainly years ago, when I was treating, hopefully not so much now understand or don't understand the fact that really there's a psychosocial and also, I'm sure, a spiritual component that for the majority of patients, rather than it's not just an ankle sprain or a hip replacement, is it? And I think the difference between a good clinician and a great clinician is understanding those non physical components. Would you agree?

Joanna: Yes. That if my therapist doesn't understand the effect of my limitation or my discomfort on my quality of life, and they're only looking to whether the part of my body works, then that erodes the relationship, because they aren't really seeing me as the whole person and as the patient and not taking me seriously in how I want to live my life. And so that's been an experience I've had differing experiences with that. I've been discharged from therapy when I wasn't really sure I was ready to be discharged from therapy because I wasn't able to do what I really wanted to do. And it's not like that old joke of saying, well, you won't be able to play the piano after you have this rehab. Well, I couldn't play the piano beforehand. So it's not that kind of I'm not able to do what I want to do. It's really helping you or helping you adapt to what you need to do. And that, I think, is doing more than just the task in front of them, but really seeing the big picture. And that takes an effort and a commitment on the part of the company that is the physical therapy company, so that the practitioners know they have that space both in themselves but also in the appointment, because you're not there by yourself. You're there with other patients, too, to be able to take that time with the patient.

Richard: Yeah, there's so much great information there. The first thing I want to perhaps highlight and explore a little bit further is I think schools are great at teaching the nuts and bolts. It doesn't matter if it's a physical therapist or any other healthcare worker with regards to diagnostics, clinical reasoning, taking measurements, doing tests, kind of the basic skills, range of motion, muscle testing, looking at how a joint is perhaps moving. And as clinicians, I think it's very safe for them, but unfortunately very restrictive in regards to perhaps how we look at patient care when they focus on those mechanics, isn't it? You talk about function. Ultimately it's can you return to something or be able to do something within either oftentimes within limits of pain, if one is fortunate, with no pain and I think as clinicians generally, we kind of forget about the big pitch and we focus on, well, you've got an extra five degrees range of motion. Well, who cares? Okay? What I really care about is being able to put my shoes on or being able to walk to the end of the road or whatever it might be. And I think that focus must always be there with a clinician, isn't it? Must return to what is the ultimate goals. And they're not range of motion, strength, they are functional in nature.

Joanna: In the kind of work that I do. I will often ask someone who doesn't have a lot of motivation for recovery, because I often take care of patients who don't have a lot of motivation. And I will say, what does a really good day look like for you? And that helps them to talk about what's most important to them and what brings them joy. And so if that is the focus for me in therapy, and people say, well, if the therapist says to me, what are you not able to do right now? Or what's impacted? What have you lost because of this injury or wear and tear on this joint, what are you not able to do? And that helps, I would hope, guide them to what graduation from therapy really looks like for me and measuring what my own motivation is for doing that, continuing to work on that strength and to work on that range of motion after I'm discharged because they can only do what I'm willing to do. That's true. It's a relationship. It's not like having a cavity filled and then you're done and all you have to do is brush your teeth.

Richard: That's right. I think we've both been in the profession long enough, or within healthcare long enough to really see that shift of the patient physician relationship from one of the patient being told to now, one that I really think is collaborative in nature. I'm sure we can always get better, but certainly things have definitely moved on. Thankfully.

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Richard: What I'd like to do is talk about your episode of therapy, or perhaps your latest episode. And I'd love to know how it went. And I think probably the easiest way is to kind of work through the episode of care. And I'd love to know what went well and what perhaps didn't go so well. And any lessons you'd have for clinicians that would listening or really it's for the leaders to be able to train the clinician. So what I often feel is the perception of care is very often set even before you meet the clinician. Unfortunately, or fortunately maybe, but usually unfortunately. And that's really through the first connection with the provider's office, through the registration process. So perhaps tell me what you remember about it and what was positive and if there are any negatives.

Joanna: The most recent episode is actually a two part because I began with one part of my body and received referral for another part of the body. And so I waited about six weeks or so before contacting my provider to say I have a similar situation with my shoulder. She knows me well enough to know that I don't complain a lot. And so she said, why don't we order some therapy and an assessment, see what they say. And I think the most difficult piece of that was getting scheduled and getting in because I needed to kind of get in a place where the person who was calling to make those appointments that we could kind of connect with each other. So there was that ability during the day for me to call them, for them to call me, kind of making sure that happened. So that was a little bit of a delay. Once I got there, I had filled out all of my forms online, but when I got to the office, I still had to fill them out in paper. And so that was a little bit of a like well, why did I go through all of those forms on my phone if I have to put them on paper again? So, because I'm a good natured patient, I just kind of go I just flipped through that and I'm noticing that a little bit more in different offices, not just physical therapy, that whether it's the switch over between electronic to paper to paper to electronic. And once I, I always try to get a 07:00 A.m. Appointment so I don't see the front staff very often because they're not there at 07:00 A.m. Anymore. And I had a really great evaluation. It kind of presented as a hip but morphed into a lower back kind of thing. And the person who did the evaluation, I really felt went the extra mile. I had never had anybody film me moving and being able to plot out and show me where things were happening. And I'm not a doctor because I didn't want to take physics and inorganic chemistry anymore, but I know enough to be able to follow along. And he read me in a way that said she will find this helpful. So it's like looking at your scans for something. Seeing is believing. I can feel things, but I can't see them. And that's what I really appreciated about the evaluation, is he could see that. So I felt really seen and listened to and invested in the person did not seem distracted. They were focused and then was really positive and confident about what he wanted to send me home with to start doing, which is really why I'm there. I'm not there to be fixed. I'm there to learn how to move in a way that helps me to stay healthy. So that was the beginning.

Richard: That's great. Well, thank you for being good natured because I think I would have probably been a little more frustrated than you, to be honest. And first off, I apologize for those things because those things shouldn't have happened for you, but I will certainly look into those. But I think I'm kind of somewhat joking aside, for certain people or new patients, that experience of doing the paperwork for the second time, I'm sure, could very easily have led to a poor perception going into the evaluation. And as a clinician, I always knew when somebody had a bad experience at the front office because I would have to de escalate. I would have to kind of manage that, spend the first 1015 minutes managing that, to be able to then go on and connect and communicate and evaluate the patient. So again, in your experience, have you seen where that initial interaction, whomever that might be, has a lasting impact on their perception of care?

Joanna: Oh, I've been that person. Yeah, I can be somebody's not good day. And I recognize that power. And so familiarity breeds contempt, unfortunately. And the staff there at this office know me well enough. So there was one day where I showed up, and the front desk person I was later that day, the front desk person was there. He was having a very hard time communicating with a non English speaking patient. And so I pulled the therapist aside in a way that was not distracting to another patient and just said, your front desk person there needs some help, needs some coaching in working with somebody who doesn't speak English. And that's a skill set, and that's a coaching thing. But even if I'm not the patient who's being helped by the front desk person, the front desk person's behavior does affect me if I can witness it in somebody else, in another patient.

Richard: Yeah, you talk about a positive experience and being provided kind of confidence, and that's critical, isn't it? Because if a patient is engaged, if a patient is comfortable, reduces anxiety, for one, and then it really improves in general engagement and willing and wants to participate in their care, isn't it? So I think as much as it's important to get objective measures, I think more so it's important to actually at least have the start of a foundational relationship in that first visit, isn't it?

Joanna: Yes, absolutely.

Richard: So you went away, hopefully, of the initial evaluation with a positive experience with the clinician, which it sounds you did, and hopefully you went away with at least some homework, a couple of exercises perhaps, or some education that you could apply. How did the following visits, how did they transpire and what was your experience with the follow up visits?

Joanna: The follow up visits were pretty straightforward. I kind of know the rituals of warming up and then, depending on what the therapist caseload is, whether I go towards some of the strengthening or stretching exercises or whether I go to a table and have manual work done and I would say feel very spoiled by the quality of the manual work that is done with this office. And I really feel like it has been a critical piece to help me be comfortable enough, but also loosening some of the tightness and some of the muscles that has prohibited some of the strengthening. And so that trust level. One of the therapists said to me one time, the manual work is really important because it really helps to build that trust with the patient and to know that patient's body. If you have different therapists for your treatment course, you kind of know what their styles are in terms of their manual therapy and what your body responds to. That's been one of the most valuable aspects of the continued care for it. There are some things that I feel like in terms of the strengthening, that I can look at them and be very clear with them that I do not like that exercise and I will do it under duress. And some of it's the perfectionist in me because it's like something that I don't do well or it takes some coordination I don't like. I told the therapist yesterday when she asked me to do an exercise and I said I'd never done that exercise before. And I said, you know what? I never tell you that I completely won't do something. I'll tell you I won't like it, but I won't ever tell you I won't do it. I'm telling you I won't do this one because I can't. It involves something that I just don't have the coordination to do. She could do it with ease, but I could not do it. But it took a couple of times because they're not used to me saying no, that's funny.

Richard: I think there's three key components to care, and I'd love for your thoughts on whether you agree. So, as therapists, the power of touch cannot be understated. I think most patients require manual component to their treatment, be that mobilizing joints, moving joints, whatever we want to call it, soft tissue massage, et cetera, et cetera. So I think the power of touch is very powerful, both from eliciting physical change, but also helping with trust, developing relationship and engagement, et cetera. Then there is the exercise component, starting perhaps very much one on one with a therapist and then gradually over the course of the care, becoming kind of semi independent because obviously you have to be able to do this eventually, independently. And I think there's the third part, which I think is sometimes lacking or oftentimes lacking, but probably the most important is the education component. I always used to think of myself as a treating clinician almost sometimes more of a teacher rather than a manual therapist. And I think that goes for pretty much all healthcare providers. That the talking about what it is, the why, the how, when, where, et cetera is just as valuable, isn't it?

Joanna: Yes. And one of the things that I really valued when I needed to shift from one part of my body to the next was receiving a lot of education about what I could continue to do to continue to build that strength and to maintain it and kind of call it the protecting of my investment. And that's on me. I have to take that responsibility as a patient to do that.

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Richard: What little things or might be very large things, but what little things stood out or you remember about your care that made the difference between a satisfactory experience and a good experience, clinical experience? Were there certain things, and they're not necessarily treatment probably. They're probably other conversations you had or engagement, certain engagement or things that were done. Can you think of anything that really stood out or contributed to your good experience?

Joanna: I really appreciate watching the environment there. And I work in an office, in my own office that have three of us now out of the five who have been patients there patients in the same location. And we all agree that the atmosphere of the office is very conducive to healing and that it isn't a time that we dread going to it's not an uncomfortable or dissatisfying environment. And that's really on the ways in which the members of the team there work together and support each other. There's really an atmosphere of cooperation. And you can say, well, that's not really about the patient, but it actually is that the other therapists know my name even though I'm not their patient. And they can also say, I haven't been your primary therapist, but I'm going to take you today and this is what this therapist has told me about you. And I've also watched you in the gym and I can see what you've been doing and I know what kind of progress you've been making. And that to me, is a sense of professionalism, that they're not there to pull a paycheck. They are there for really that goal of helping patients to feel better and to be stronger and to have healthier bodies again.

Richard: It's interesting how I think healthcare professionals have changed over time to when I trained as a physical therapist a little while ago, it was very much you bring your patient, you kind of whisper the name of the patient in the waiting room almost. And then you usher them through a door very quietly as if somebody is like a library almost. And then you kind of usher them into a private treatment room and then you do whatever the manual therapy is and then you usher them back out, usually through a different exit almost. Or certainly in a lot of departments I've used. And looking back, I feel that I lost a great opportunity to collaborate with other clinicians and for the patient to be able to collaborate with other clinicians. And it's interesting that the clinics where we get the best Net Promoter score, patient satisfaction are definitely those where it's a team treating the patient. And very often with the comments that we get back, they list out all the people that were involved in their care. And usually it's the tech or front office person that's at the first one mentioned and the last one mentioned is actually their primary therapist. So this concept of a team and everyone a very positive environment, very welcoming environment. Some might say it's even busy, but hopefully you never got that impression. It was too busy. But I think that all contributes to the episode, doesn't it?

Joanna: From what I'm hearing well, and if you tend to have a similar appointment time, then you get to know the people who are in your same appointment slot. And there were days when I would turn to the next patient and I would say, okay, I see that you're doing that today. And you kind of mutually encourage each other and there's a certain amount of ribbing that goes along with the therapist, so try to keep it in a good hearted way.

Richard: I would even go to the point where if I had people with a similar condition, I would schedule them close together, particularly if they were different phases of recovery to help with that reducing anxiety overall with regards to hey, you can do this, I did that four weeks ago and look how I'm doing now. And I think some clinicians are afraid that that interaction between different patients might dilute the care. But I think it's the opposite, isn't it?

Joanna: Yeah, definitely. And if I have a major joint replaced in the next few years, I will want that kind of thing because I'll want to see what I would be looking at in another month.

Richard: That's correct. Anything else that you can think of that really contributed to your perception of a good experience? Perhaps it was how they approached you. I know we've talked about a few different things already. To me, it's the difference that I feel is anticipating patients needs before they ask or before they vocalize it, for instance, that's really the difference for me between good and great. Did you have any experiences where an individual recognized something without even being told, for instance, or they communicated in a certain way that really indicated the difference between good and great care, et cetera?

Joanna: In the last month or so, the location where I've been has had some scheduling changes of their therapist and so I was at a point in my recovery that I think they felt comfortable with me going to see therapists who had less experience, less clinical experience, and I really appreciated that that was communicated to me. So that was something that was anticipated that they could say, I think the next few weeks you're going to be with these two people and they're going to be kind of taking care of you. And that was much better than just kind of showing up one day and having that announced to me. So being able to prepare a patient for those kinds of shifts, I think is really important and I've been in this location long enough that I understand it and I understand the needs yes.

Richard: Always has to be that warm handoff, doesn't there, between people? And sometimes you don't get that, certainly physician offices where you walk in, oh, Doctor, such and such is out today, but there was no prior communication and I understand the administrative burden associated with trying to reach out to patients, et cetera. I'm not saying that it's terrible, but it's certainly, from a patient perspective, your anxiety level, without that knowledge, anxiety level immediately increases, doesn't it? Otherwise?

Joanna: Yes. And they were able to tell me the visit beforehand because they could look at the schedule and say, I think next week you're going to be with so and so and so and so and that's helpful. That's a really helpful way to do it. It says, we care about you, we take you seriously and you're not just a patient coming in to get there to get our service. We understand that we have a relationship with you.

Richard: Yeah. And to me, the experience isn't really one defining factor that makes it either good or great. It's lots and lots of little things, isn't it? So it's, for instance, walking in and having a smiling face being acknowledged within the first 10 seconds and said hello within the first 30 seconds, being greeted by your name in a manner that you wish to be greeted by. It's being not having to wait, or if you do have to wait, having an explanation of apology and explanation of why and then a positive experience where you're not having to deal with any non work baggage from employees, for instance. It's cumulative, isn't it? It's lots of little things and they have to then be tailored to each patient to a certain extent as well right.

Joanna: And to the point of all of those pieces of good care and to great care. I then witness over the course of X number of patient visits, all the other patient visits, like all the other patients in my hour that I'm there, all their experiences, because it's such a public thing. I don't see their evaluation, but I see them come in. So I hear somebody say to the patient, greeting them by their name and saying, come on back or we're going to be with you in a minute, we see you. We want to recognize that you're there. And then I see them, how they're treated in the gym. And again, how I'm treated affects other patients, how they're treated affects me because it's public. And I think that I have a lot of admiration for the therapists because I would say they're in a fishbowl all day. There's no private work that they can do with a patient necessarily. And that's a lot.

Richard: Yes. I can always tell what a company is like or what a local leader is like by the tone in which is set within the facility because it permeates, doesn't it? And it's contagious either in a positive way or unfortunately in a negative way as well, isn't it so definitely tone of the facility is critical. And again, I think as a consumer of healthcare, as a patient, you can feel it, can't you, very quickly when you enter a facility? I know that as soon as I walk in oftentimes, just how the front office staff interact with each other is a good indication of the tone in which is set throughout the facility, isn't it?

Joanna: Right. My husband has been caring for his mother, who's very elderly and in different offices that he's needed to take her. He said, boy, the front desk people, boy, they need some help. And so I think that we don't give enough credit to the front door and the ways that they also need the support because they have that initial anxiety that they have to manage on the part of a new patient too, who doesn't know where they are and doesn't know where they're going. I have some compassion for them.

Richard: We've talked about what contributed to your good experience and we've mentioned a couple of things that didn't go quite so well, one of them being the onboarding and unfortunately having to do the paperwork a second time. Were there any other things that you experienced in this episode that perhaps detracted slightly or made you question the care or made you a little more anxious? Perhaps.

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Joanna: I don't think that I have had anything that's made me anxious. I'm pretty good at being my own advocate. And so if I can't do something, won't do something, need to change, I don't generally wait for someone to notice that I speak up and ask about it. That has served me well.

Richard: I think that's a very good point with regards to self advocacy, because I think with your extensive experience within healthcare, I think we do become much more comfortable with becoming advocating for ourselves. But the average patient, I believe, struggles with that, don't they? And I think that's oftentimes why certain get certain either poor outcomes, but more often than not actually self discharge or cancellation, isn't it? And I believe that, yes, there's always a certain level of cancellation due to external factors. But a lot of the reasons why people just don't show is because of that disconnect, isn't there?

Joanna: It is. And I would have to say that I would be inclined to ask myself what is it that I need to do between now and the next visit? Or what is it that you expect of me when I'm here? I also appreciate when a therapist says, this is what you were able to do two weeks ago, and this is what you're able to do now. And kind of being able to notice that progress and actually give me that feedback is helpful to that motivation to keep coming. And I appreciate being told, oh, you did a good job today, or you did great today, or you're looking really good today. I think it's okay to ask a patient, what kind of feedback do you want from us? What would be helpful to you? Would it be helpful to you to know how your range of motion is going or how maybe you were able to do this much weight today and this is how much weight we hope you can do in two weeks. These are some of your goals. And I would say that would be the only thing that I haven't asked for it. I could always ask for it. But that's something to consider with different patients is what would be helpful to you, what's a helpful motivator, what do you want to feel better? And that may happen in the initial assessment, but whether that's kind of continuing to happen throughout the course of treatment too, to help revisit that, because it does get not this most recent episode, but a different episode where it took a really long time and that was discouraging.

Richard: One of the number of challenges we have in therapy, and again is not unique to therapy is the payers somewhat, should I say, direct care. And what I mean by that is essentially through cost of service and also authorization for visit, frequency and duration. And I unfortunately feel that that's compromised the care in regards to we treat based off insurance sometimes rather than based off patient need and to follow up from that is I fear that we aren't necessarily giving the patients what they deserve, need and want and we assume that care will be delivered based on purely financial need. And whilst I certainly don't dismiss the fact that a lot of people don't have significant income that can just pay for lots of copays or deductible, I understand that. But I think we're doing a disservice to patients, aren't we? When we frame recovery based around purely financial rather than based around functional need and what your wishes are, we can always work out the finance with payment plans, et cetera, et cetera. But I think it's really important that in healthcare generally we don't just treat or rehabilitate to good enough, we try and treat until we've optimized functional outcomes. Does that resonate with you?

Joanna: Oh yeah. I feel very fortunate in the kind of insurance I have in terms of the number of visits I can have annually that I made a choice, along with my husband, to invest our deductible amount in one year on physical therapy because that was the stage of my life, of our lives that we were in. And I have that. I am fortunate with that. But when I needed to have physical therapy on a second part of my body I had to finish enough or to that good enough level that you had in order to go to the second part because the insurance would not let me have two parts of my body being treated at the same time. To that point the insurance was dictating. I had to decide am I in pain more in this part of my body or am I in pain more? I had to make that decision. I'm in that predicament again but I see that chronically throughout my work and then as a consumer. So it is not functional health care at this point. It is episodic, it is acute based. I've said for many years that after age 50 I think everybody should have to get a physical therapy assessment at least once a year or every two years to correct things that are going to become problems later.

Richard: That's a great advocate for therapy. So thank you for this episode. What I'd love to perhaps finish up with is really understanding if there were other things very practical probably, but were there other practical things that could have been done that would have made your experience better? And it might be applying certain things that you've seen in other healthcare environments that could have complemented what was already done not just from a clinical perspective but really from the whole patient experience from beginning to end. What could have been done to perhaps improve your experience further or even what were the key things that were done that really define were truly definitive of a good experience? Because I know you've had some poor experience or a poor experience in the past so what was the difference between the prior episode and this episode? Perhaps.

Joanna: The thoroughness of this episode is what is most impressive to me. The kinds of manual therapy and the kinds of strengthening and stretching that I'm doing isn't just in one isolated part of my body, because I have this sense of confidence and trust that we're not treating my whole body, but we're treating the interconnectedness of my body. Because to just treat it isolating would not allow the whole body to function well. And I have enough body awareness that I understand that and that really builds that confidence in me that I can go there and they're going to tell me what I need to know and they're going to tell me what my body is doing and they're going to coach me through this. And so I have a partner in that and I don't feel as isolated in my getting through middle age. That's what it is.

Richard: Yeah. When we talk about engagement, we regularly talk about engagement from the patient, but I think equally important is the engagement of the clinician, isn't it? And if the clinician is engaged, then they're more likely to be more thorough or thorough enough, et cetera. And as a leader, I try my very best to make sure that I provide an environment where the therapist is engaged, because I know that if the therapist is sufficiently engaged and positive, then that will be reflected in the patient experience as well. And unless the employee is engaged, they're not going to give that thorough evaluation. And I think the tone of the organization is reflected in large part by the employees and how they interact with the patients.

Joanna: I had a conversation yesterday with the therapist about that individual's vacation and I had an upcoming vacation and she had been to that place and we were able to talk about what was happening. And she had a memory of another time when I had been on vacation and what we had done and what we enjoyed. And so being seen as a whole person in the active way, not just what tourist thing did you do, but she knew that I liked to hike. And so that piece of it, she's engaged in her own life and she's engaged in my well being and what brings me joy. And as you said earlier, there are all these small things that add up and that's what I appreciate in this place.

Richard: Well, thank you so much, Joanna, for your time today. I think it's been very insightful and hopefully the physical therapy leaders listening to the podcast have found it likewise. So appreciate the information. I'm glad that they had a great experience.

Joanna: Thank you so much. It's been a joy.

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