december 2018 vol. 18 // no. 4 · ffe physical ffierapy journal of policy, administration and...

Official Publication of the Section on Health Policy & Administration of the American Physical Therapy Association

Physical Therapy Journal of Policy, Administration and Leadership

December 2018Vol. 18 // No. 4

Vol 18 Issue 4 Physical Therapy Journal of Policy, Administration and Leadership

Articles accepted via our online submission system. Visit www.aptahpa.org/PTJPAL for more information and to submit your manuscript.

The Physical Therapy Journal of Policy, Administration and Leadership (PTJ-PAL) is a publication of the Section on Health Policy & Administration. The Section reserves all rights through the Editors, Officers, and Executive Director to refuse publication of any advertisement or sale of member list.

All advertisements or orders are accepted on the basis of conformance with the APTA Code of Ethics, Standards of Practice, and the policies and positions of the above sections. Acceptance of advertisement or use of lists by another party does not imply endorsement by HPA The Catalyst: Section on Health Policy and Administration of APTA.

Articles published in HPA PTJ-PAL are the work of the authors and do not necessarily represent the opinions, research, or beliefs of HPA The Catalyst: Section on Health Policy and Administration of the APTA.

2019 Submission Deadlines:Jan. 9, 2019 (digital release date – Feb. 4, 2019)April 5, 2019 (digital release date – May 6, 2019)July 12, 2019 (digital release date – Aug. 5, 2019)Oct. 4, 2019 (digital release date – Nov. 4, 2019)

ISSN: 1931-6313HPA Resource/PTJ-PAL is indexed by EBSCO. www.ebsco.com.

HPA The Catalyst is the Section on Health Policy and Administration, a specialty section of the American Physical Therapy Association.

Join HPA The Catalyst for CSM 2019 Pre-Conference Sessions

HPA The Catalyst will host four Pre-Conference sessions at the Combined Sections Meeting (CSM) 2019 in Washington, D.C., Jan. 23-26, 2019.

Read about the offered courses below, and register for one at www.apta.org/csm.

LAMP Leadership 101: Personal Leadership Development: The Catalyst for Leading

WithinTuesday and Wednesday, Jan. 22-23, 2019

8:00 a.m.-5:30 p.m.This course is the first in the series of courses and applied labs aimed at developing leadership skills. As the first course in the series, the program focuses on developing your personal leadership skills. In order to successfully lead others, you must understand yourself. Content focuses on self-assessment, creating a personal mission statement, foundations of leadership, identifying personal styles, creating a leadership style to align and influence others, energy and time management, communication for effective leadership, conflict resolution styles and skills, and implementing personal leadership development plans. There

are approximately 4 hours of prework for this course. This pre-conference is a HIGH B pricing.

Community Health Promotion Grant Writing WorkshopWednesday, Jan. 23, 2019

8:00 a.m.-5:30 p.m.This grant writing workshop is designed for clinicians and researchers wishing to seek grant funding in support of community health promotion programs. This course will provide didactic presentations, opportunities for practical applications of the material, and opportunities for small-group grant review.

This pre-conference is a LOW A pricing.

LAMP Management 101: Practical SkillsTuesday and Wednesday, Jan. 22-23, 2019

8:00 a.m.-5:30 p.m.The speakers will cover performance management, human resources, legal considerations, regulatory aspects, compliance issues, communication, project/program management, finance, and budgeting. This case study and scenario-based course will examine current issues and address current trends faced by the new manager and developing manager and will provide participants with the tools to effectively and efficiently get the

“work” done through systems and people. This pre-conference is a HIGH B pricing.

LAMP Leadership 201: The Catalyst for Leading Others

Tuesday and Wednesday, Jan. 22-23, 2019 8:00 a.m.-5:30 p.m.

In this course, attendees will further explore and develop effective leadership skills in formal and informal leadership roles. Attendees will share the results of their personal leadership plans, showcasing insights into developing their personal leadership behaviors. This course will include lectures, dynamic leadership labs, and engaging discussions with peers and content experts. Topics will include: creating vision and strategy; fostering adaptive and transformational leadership; creating cultures of change and innovation; leading others through conflict; building relationships and networking; implementing frameworks for leadership decision making; building high-performance teams; leading and learning through failure; empowering others; fostering followership; and developing a personal leadership philosophy statement. There are approximately 5 hours of prework for this course. Successful completion of LAMP Leadership 101 is required

before continuing onto LAMP Leadership 201.This pre-conference is a HIGH B pricing.

3

TABLE OF CONTENTS HPA the Catalyst


PresidentIra Gorman, PT, PhD, MSPH

[email protected]

Vice PresidentKaren Hughes, PT

[email protected]

SecretaryJames Eng, PT, DPT, MS, GCS

[email protected]

TreasurerTina Gunaldo, PT, DPT, PhD, MHS

[email protected]

Director of ScholarshipDawn Magnusson, PT, PhD

[email protected]

Director of OperationsAmit Mehta, PT, DPT, MBA

[email protected]

Director of Social Responsibility & Global Health

Jennifer Audette, PT, [email protected]

Director of Technology & InnovationRobert Latz, PT, DPT, CHCIO, [email protected]

Director of LAMPEmily Becker, PT

[email protected]

Publications ChairEd Dobrzykowski, PT, DPT, ATC, MHS

[email protected]

Managing Editor • PTJ-PALDianne V. Jewell, PT, DPT, PhD,

[email protected]

Section Office • Editorial Coordinator Caitlin Price

2400 Ardmore Blvd Ste 302

Pittsburgh, PA 15221877-636-4408

[email protected]

Vol 18 Issue 4 Physical Therapy Journal of Policy, Administration and Leadership

Articles accepted via our online submission system. Visit www.aptahpa.org/PTJPAL for more information and to submit your manuscript.

The Physical Therapy Journal of Policy, Administration and Leadership (PTJ-PAL) is a publication of the Section on Health Policy & Administration. The Section reserves all rights through the Editors, Officers, and Executive Director to refuse publication of any advertisement or sale of member list.

All advertisements or orders are accepted on the basis of conformance with the APTA Code of Ethics, Standards of Practice, and the policies and positions of the above sections. Acceptance of advertisement or use of lists by another party does not imply endorsement by HPA The Catalyst: Section on Health Policy and Administration of APTA.

Articles published in HPA PTJ-PAL are the work of the authors and do not necessarily represent the opinions, research, or beliefs of HPA The Catalyst: Section on Health Policy and Administration of the APTA.

2019 Submission Deadlines:Jan. 9, 2019 (digital release date – Feb. 4, 2019)April 5, 2019 (digital release date – May 6, 2019)July 12, 2019 (digital release date – Aug. 5, 2019)Oct. 4, 2019 (digital release date – Nov. 4, 2019)

ISSN: 1931-6313HPA Resource/PTJ-PAL is indexed by EBSCO. www.ebsco.com.

HPA The Catalyst is the Section on Health Policy and Administration, a specialty section of the American Physical Therapy Association.

Letter from the Managing Editor D. Jewell, PT, DPT, PhD, FAPTA

PRACTICE ADMINISTRATION Preliminary Investigation of Reasons Patients Miss Scheduled Appointments in Outpatient Physical Therapy K.E. Randall, PT, PhD // J.E. Miller-Cribbs, MSW, PhD // S.M. Schaefer, MArch, AIA, NCARB, AICP, CUD // J.E. Bragg, MSW, PhD

PRACTICE ADMINISTRATION A Model for Measuring and Clarifying Staff Expectations Following Organizational Restructuring in Rehabilitation Services, with Applications in Management and Workforce Development A. Lotshaw, PT, PhD // M. Thompson, PT, PhD

4

5

16

Community Health Promotion Grant Writing WorkshopWednesday, Jan. 23, 2019

8:00 a.m.-5:30 p.m.This grant writing workshop is designed for clinicians and researchers wishing to seek grant funding in support of community health promotion programs. This course will provide didactic presentations, opportunities for practical applications of the material, and opportunities for small-group grant review.

This pre-conference is a LOW A pricing.

LAMP Leadership 201: The Catalyst for Leading Others

Tuesday and Wednesday, Jan. 22-23, 2019 8:00 a.m.-5:30 p.m.

In this course, attendees will further explore and develop effective leadership skills in formal and informal leadership roles. Attendees will share the results of their personal leadership plans, showcasing insights into developing their personal leadership behaviors. This course will include lectures, dynamic leadership labs, and engaging discussions with peers and content experts. Topics will include: creating vision and strategy; fostering adaptive and transformational leadership; creating cultures of change and innovation; leading others through conflict; building relationships and networking; implementing frameworks for leadership decision making; building high-performance teams; leading and learning through failure; empowering others; fostering followership; and developing a personal leadership philosophy statement. There are approximately 5 hours of prework for this course. Successful completion of LAMP Leadership 101 is required

before continuing onto LAMP Leadership 201.This pre-conference is a HIGH B pricing.

Vol 18 Issue 4 Physical Therapy Journal of Policy, Administration and Leadership4 Physical Therapy Journal of Policy, Administration and Leadership Vol 18 Issue 4

Lasting thanks to our 2017-2018 reviewers:

Dianne V. Jewell, PT, DPT, PhD, FAPTA

Full transparency here…I’m still riding high on the Red Sox world series win!! For those who only know me from Virginia, I am a native of the Boston area and started going to Fenway

Park in elementary school. Coincidentally, “Field of Dreams” recently resurfaced on a cable movie channel. If you’ve never seen the movie, then you won’t recognize the reference in this editorial’s title. Crib notes version: Lead Kevin Costner’s character is inspired to create a baseball diamond in the middle of an Iowa cornfield, in part because a nameless voice insists, “If you build it, he will come.”

That notion is seductive in its simplicity. Just create something and one or more people will instantly want in. If only it were that easy! We know from numerous studies of successful business leaders, sports figures, artists and inventors that a lot more work is required to attract peoples’ attention, persuade them that you have something valuable to offer, and keep them engaged after they get there. It was seven years between the delivery of the Apple II computer and creation of the Macintosh version, and another 17 years before the wildly successful iPod’s release. Even Steve Jobs needed a spell to figure it out!

The fantasy of "Field of Dreams" was that this baseball field would deliver on its promise simply through its existence. That’s not to say success isn’t built on dreams – just a reality check that dreams are more likely to be fulfilled when vision and persistence meet grit and a roll-up-your-sleeves work ethic. That’s how we’re approaching HPA The Catalyst’s dream of transforming PTJ-PAL into a fully indexed journal that is sought after by authors and readers alike. My role is to map our course. The yeoman’s work is executed by our team of reviewers. It is their thoughtful mentorship throughout the manuscript development process that brings you meaningful information to consider.

Two examples are presented in this issue. What they share is a focus on the opportunities and challenges in bringing people along with you. Randall and colleagues offer a pilot exploration of reasons why people miss their therapy appointments. This work has real-world implications

in terms of ensuring access to necessary services as well as addressing the workflow and financial impacts on the practice that result from upended schedules. Lotshaw and Thompson, on the other hand, survey their colleagues’ expectations about their work environment following an organizational restructuring. An important nuance in this piece is the need for department and health system leadership to understand the relationship between “expectations” and “satisfaction” in order to attract, motivate and retain their talent base.

These articles remind us that understanding others’ needs, wants and interests is essential to addressing logistical and interpersonal impediments to participation and engagement. A clinic or health care system’s existence alone does not guarantee patients will come or employees will stay. Similarly, “building” this journal in a vacuum will not attract more authors or readers. With that, I invite you to send me your thoughts about PTJ-PAL – what you appreciate, where improvements are needed, and what you hope for the future. You’ll find me at [email protected]. Until then, wishing you all a festive holiday season.

Dianne V. Jewell, PT, DPT, PhD, FAPTA

PTJ-PAL Managing Editor

LETTER FROM THE MANAGING EDITOR

Kenneth E. Randall, PT, PhD // Julie E. Miller-Cribbs, MSW, PhD //Shawn M. Schaefer, MArch, AIA, NCARB, AICP, CUD // Jedediah E. Bragg, MSW, PhD

“If You Build It…”

Jennifer Audette, PT, PhD

Sujoy Bose, PT, DPT, MHS, BSPT

Julia Chevan, PT, PhD

Janet Dolot, PT, DPT

Edward Dobrzykowski, Jr., PT, DPT, ATC, MHS

Hilary Greenberger, PT, PhD, OCS

Gaurav Kaushik, PT, DPT, MBA, MS

Cheryl Kerfeld, PT, MS, PhD

Nancy Kirsch, PT, DPT, PhD, FAPTA

Dawn Magnusson, PT, PhD

William McGehee, Jr., PT, PhD

Beth McManus, PT, MPH, ScD

Sue O’Brien, PT, PhD

Susan Roush, PT, PhD

Robert Sandstrom, PT, PhD

Shawne Soper, PT, DPT, MBA

Laura (Dolly) Swisher, PT, MDIV, PhD, FNAP, FAPTA

Ralph Utzman, PT, PhD

John Wallace, PT, MS

Jaclyn Warshauer, PT

Jean Weaver, PT, MBA

5

ABSTRACT

Vol 18 Issue 4 Physical Therapy Journal of Policy, Administration and LeadershipPhysical Therapy Journal of Policy, Administration and Leadership Vol 18 Issue 4

Lasting thanks to our 2017-2018 reviewers:

PRACTICEADMINISTRATION

Preliminary Investigation of Reasons Patients Miss Scheduled Appointments in Outpatient Physical Therapy

Kenneth E. Randall, PT, PhDAssociate Dean & Associate Professor, Program in Physical Therapy, College of Allied Health University of Oklahoma Schusterman CenterTulsa, OK

Julie E. Miller-Cribbs, MSW, PhDDirector, Anne & Henry Zarrow School of Social Work, College of Arts and SciencesUniversity of Oklahoma Schusterman CenterTulsa, OK

Shawn M. Schaefer, MArch, AIA,NCARB, AICP, CUDAssociate Professor of Architecture, Director, Urban of Design Studio, College of ArchitectureUniversity of Oklahoma Schusterman CenterTulsa OK

Jedediah E. Bragg, MSW, PhDSenior Research Fellow, Hope Research Center, University of Oklahoma–TulsaPostdoctoral Research Fellow, Anne and Henry Zarrow School of Social Work, College of Arts and Sciences, University of Oklahoma Schusterman CenterTulsa, OK

Kenneth E. Randall, PT, PhD // Julie E. Miller-Cribbs, MSW, PhD //Shawn M. Schaefer, MArch, AIA, NCARB, AICP, CUD // Jedediah E. Bragg, MSW, PhD

Corresponding Author:Kenneth E. Randall, PT, PhDCollege of Allied HealthUniversity of OklahomaSchusterman Center4502 East 41st StTulsa, OK, [email protected]

“If You Build It…”

Background. Missed healthcare appointments, when a patient cancels, reschedules, or simply does not appear for an appointment, have significant impact on individual and community health. They have social consequences by contributing to poor health outcomes, missed revenue, disrupted workflow, and higher costs for care.

Methods. This descriptive study was conducted at a physical therapy clinic associated with a university health center in the Midwest United States. Its purpose was to directly ask patients why they missed or cancelled their appointments using a survey consisting of twelve literature-informed categories of reasons plus a 13th write-in response. Differences in reasons due to demographics, geographic location, insurance provider, tobacco use, and disability status also were explored. Ninety-seven individual patients from a random sample of 177 were contacted over 14 months.

Results and Discussion. Wednesday was the most frequently missed day of the week. The top four reasons for missing an appointment were “scheduling error,” “too sick or tired,” “could not get off work,” and “family situation or emergency.” No significant differences between ethnicity, sex, or disability were found. Significant differences were noted in age group and type of insurance. Qualitative data suggest that some missed appointments might be related to social determinants of health or possibly adverse childhood events. These factors will be included when this study moves from pilot to full implementation across additional clinic settings with more patients.

Key words. Missed appointment, patient, cancellation, no-show.

Approval. This consent process and the entire study was approved by the University of Oklahoma institutional review board for the protection of human subjects involved in research.

Acknowledgements. The authors wish to thank the following individuals for their invaluable contributions to this study:

Amanda Yamaguchi, MS | Staff Planner, City of Broken Arrow | Broken Arrow, OK

B. Paulina Baeza Pinal, MS | Transportation Planner, Indian Nations Council of Governments | Tulsa, OK

Maryam Moradian Mosleh, MS | Master of Urban Design, College of Architecture, University of Oklahoma Schusterman Center | Tulsa, OK

Shakendra Leathers, MSW, LMSW | Outptient Social Worker, U.S. Dept. Of Veteran AffairsTulsa, OK

Amanda C. Maxwell, MSW, MPA | Graduate Research Assistant, College of Arts and Sciences, University of Oklahoma Schusterman Center | Tulsa, OK

Laura (Dolly) Swisher, PT, MDIV, PhD, FNAP, FAPTA

Ralph Utzman, PT, PhD

John Wallace, PT, MS

Jaclyn Warshauer, PT

Jean Weaver, PT, MBA

6 Physical Therapy Journal of Policy, Administration and Leadership Vol 18 Issue 4


IntroductionMissed healthcare appointments have a significant impact on individual and community health. A missed appointment is one in which a patient cancels or reschedules less than 24-hours before their appointment, or simply does not arrive.1

Cancellations occur when patients notify the provider they cannot attend their appointment. A “no-show” occurs when patients do not attend their appointments without informing the provider. In many health clinics, nonattendance for physician appointments can account for a significant percentage of all scheduled appointments with rates ranging widely from 10% to 50%. Rates in the 20% to 30% range are common.2-6

Missed appointments have significant social consequences by contributing to poor health outcomes due to lack of prevention, treatment, and follow-up care.6

They also impact the efficiency of the clinic site and the health care system broadly. For instance, Moore et al. found in their study of a family medicine clinic that missed appointments cost 14% of total revenue.3 Missed appointments mean providers may not be available to other patients needing care and needed revenue will go uncollected.7 Missed appointments can also disrupt workflow, stimulate negative clinician attitudes and negatively impact recovery time.8,9,10 Patients who miss their appointments may also seek care at an emergency room where the cost is many times higher than at a scheduled clinic appointment.1

Previous research has found multiple factors contribute to patients cancelling and missing appointments at physician practices. Several studies have examined the relationship between demographic factors such as sex, race, ethnicity, age, educational attainment, and insurance status and missed appointments. Some studies have found younger patients are more likely to miss appointments.7, 11-12 There is also some evidence that people who are Caucasian and Asian miss fewer appointments than

other groups, while Medicaid patients make and miss more.7

Patient health status was investigated in many studies, including diagnoses, chronic illness, hospital admission rates, improvement of symptoms, anxiety, depression, and tobacco, alcohol and drug use.2,7,11,13 No strong evidence exists to support a relationship between different diagnoses, chronic illness, or substance abuse with missed appointments.5,7 Few studies have directly asked patients why they don’t arrive for appointments. One qualitative study interviewed 32 women and two men with a median age of 40 years and found three themes: Emotional barriers (with negative emotions about going to the appointment being most frequent), perceived disrespect from the healthcare provider, and a lack of understanding of what happens in a clinic if there is a missed appointment.14

Operational factors, such as day of the week, time of day, scheduling interval, number of previous appointments, use of reminders, and provider identity and type have also been studied. Evidence is mixed for predicting which day of the week has the most missed appointments. One large study found the rate was highest on Monday and declined as the week progressed.12 Another study looking at eight years of data found Wednesdays had the highest rates. The same study also found that missed appointment rates are higher in the afternoon than in the morning.4

Scheduling errors accounted for a high percentage of missed and cancelled appointments. Missed appointments are often attributed to forgetfulness and lack of reminders.5,11 Several studies found a connection between proximity to the clinic or access to transportation and no-shows with poorer populations facing greater barriers.7,15,16 Studies looking at staff rapport and concordance in terms of race, sex, and language proficiency did not find significant differences in nonattendance rates, but did note differences between clinic sites.4,12,17 In one case, cancellation

rates for staff physicians and residents were the same, but residents had more no-shows.4 It is unclear if staff turnover contributes to nonattendance.17

Studies specifically investigating missed appointments at physical therapy clinics are sparse. Mbada and colleagues reviewed case files of patients who missed appointments over a two-year period at a teaching hospital in Nigeria. They found that people over 65 years old, who lived farther from the clinic, or were referred by consulting physicians rather than self-referral were more likely to miss an appointment.1 A nationwide survey of 802 physical therapists reported a no-show rate of 10.4% (+/- 7.43) with the number one reason as reported by the therapists for clinic no-shows being “forgot” followed by “illness” and “transportation.”18 A systematic review of 20 high-quality studies investigating barriers to treatment adherence, which could potentially extend to missed appointments, showed that physical therapy patients who had lower activity levels, greater number of physical impairments (with pain being the most common), and low levels of social support to be less adherent.19

The bulk of the missed appointments literature involves retrospective studies conducted at physician clinics, with most of the data being extracted from medical records or workflow analytics. The purpose of this pilot study was to directly ask patients why they missed or cancelled appointments using standard categories informed by the literature to classify their reasons as well as collect more in-depth explanations related to each category about why they missed their appointment. A secondary purpose was to explore whether differences in reasons occurred based on demographic characteristics, health status and geographic location of participants.

MethodsThis cross-sectional pilot study was conducted at an urban outpatient physical therapy clinic associated with a university health center in the Midwest United States. Similar to what is reported in

Physical Therapy Journal of Policy, Administration and Leadership Vol 18 Issue 4 Vol 18 Issue 4 Physical Therapy Journal of Policy, Administration and Leadership 7


the literature,18 the clinics at this center experience missed appointment rates in the 20% to 30% range, which has a significant impact on clinic operations and revenue. The clinic operates from 7:30 a.m. to 6:00 p.m. Monday through Friday and manages patients across the lifespan with most of them having musculoskeletal diagnoses and a smaller number having neurological diagnoses. There is a mixture of referral sources, with about 60 percent of referrals from in-house physicians, 30 percent from outside practices, and 10 percent self-referral. The payer mix is also varied with about a third being Medicare, more than half being private insurance, and about four percent Medicaid. Although reimbursement rates vary by payer, each missed appointment equates to an average of $85 in lost revenue. With an average of 119 missed appointments per month, this equates to just over $10,000 per month and over $121,000 annually. Guzek and colleagues reported a similar no-show rate of 26% at an academic pediatric neurology clinic with monthly losses between $15,000 and $27,000, and annual loss around $257,000.20 Even with similar rates of missed appointments, the differences in reimbursement between medicine and physical therapy may account for the disparate financial losses.

Sample

The sample for this study was randomly drawn from a list generated each week by the Allscripts® scheduling software program of patients who missed their outpatient physical therapy appointments. A random number generator was used to select 10-15 patients from the list, which was numbered and organized chronologically by date and time of missed appointment. For weeks when fewer missed appointments occurred, ten patients were selected and for weeks with more missed appointments fifteen were selected. Patients were selected using the first 10-15 numbers generated. The clinic director accessed the electronic medical record (EMR) to record patient phone number and demographic information

on the survey form along with the time, day, and date of the missed appointment generated from the scheduling program.

The patients were contacted by telephone within a week of the missed appointment. Research assistants made three attempts to contact the patient and, when possible, left messages. Of 177 eligible subjects, 97 patients (54.8%) consented to participate, 19 declined to take part in the study, and 61 could not be reached at the phone number recorded in the EMR.

Survey Instrument

Many studies solely use demographic and appointment data from patient records to characterize patient behavior without directly asking the patients why they did not attend their appointment. This study asked patients to give the reason for missing their appointment, as well as using data gleaned from their records. The authors reviewed a wide range of previous studies from many different health care environments to develop the most common reasons patients miss their appointments. Since no consensus exists on which reasons to include, the survey attempted to be inclusive by using all the common reasons and providing respondents the opportunity to provide new reasons not enumerated on the list (Table 1).5,11, 21-25 One potential reason not identified in the literature, “I started feeling better” was added to the list of possible options. In all, the survey contained 12 reasons for missed appointments. In anticipation of patients not attending for a reason not on the list, a thirteenth option of “Missed for another reason” was established, with space to record the unique response.

Each of the 12 reasons contained follow-up questions to attain greater detail related to that reason (Appendix 1). For instance, if a patient said they forgot the appointment, they were asked if they wrote or recorded the appointment somewhere, if they kept a calendar, if they received a reminder from the clinic and, if yes, how they were contacted. The survey also included demographic information based on

variables identified as possibly significant in other research studies, including: patient address, zip code, sex, age, race, Hispanic origin, educational attainment, disability, insurance status, insurance provider, and tobacco use. Appointment information included the date, day, and time of the missed appointment, whether the appointment was cancelled or missed, the provider name and the number of prior missed appointments with the provider. The survey form was designed so that it could be administered as a telephone interview.

Data Collection Process

Research assistants received standardized training to acquire consent and conduct the interview following a specified format. If the patient answered the phone, they were read a script and asked for their consent to participate in the study. They were told the purpose of the study was to find out why people did not attend their scheduled appointments and the answers they provided would be used to improve practices and service at the clinic. They were told that any information collected would not be recorded with their name or any code that could be traced to them and that results of the study would be reported in aggregate form. Furthermore, their responses would not be recorded in or linked to their medical records. They were told the survey was voluntary, would last less than five minutes, and that they could quit at any time without penalty. They were offered no compensation or inducement to participate. Any patients who missed more than one appointment and had been randomly selected a subsequent time were not interviewed again. This consent process and the entire study was approved by the university's institutional review board for the protection of human subjects involved in research.

If consent was received, the interviewer reviewed the basic demographic data with the patient, then asked the primary survey question: What was the main reason that you missed or cancelled your appointment? Patients could give more than one reason,



but if they did, they were asked to identify the primary reason. If a patient stated one of the twelve reasons, the patient was asked if they ever missed appointments before for the same reason and the responses were recorded. Patients were also asked if they received a reminder from the clinic and which method was used to remind them: postcard, email, text, or phone reminder.

The interviewers asked the follow-up questions pertaining to the main reason stated. The interviewers made notes on the surveys of any comments that the patient made that they believed would add clarity to the response. Data were collected during a 14-month time frame. A main reason for conducting the study over the course of a year was to determine if weather played a role in missed appointments, since the weather for this region of the Midwest is quite variable, including rain, snow, ice, and severe weather, as well as temperatures that can range from sub-zero to well over 100 degrees Fahrenheit.

Analysis

All completed surveys were entered into a Microsoft® Excel spreadsheet for data analysis. Some surveys contained incomplete demographic information, in which case the lead author accessed the EMR to retrieve this information and add it to those surveys, which were then included for analysis. Surveys that had one of the twelve reasons identified were entered into the appropriate field with responses to additional follow-up questions entered as well.

The field for the write-in category of “Missed for another reason" allowed for the entry of descriptive text. Upon first examination of the surveys, 48 patients had extensive detailed notes under “missed for another reason.” Examples of this included: “I had another health problem that was more serious and had to attend to first,” “Conflict with another appointment,” and “Had a flat tire.” It was apparent that many of the write-in responses were linked with

one of the twelve reasons. As such, the study investigators met to discuss recoding these responses into the proper categories where possible. To support measurement adequacy, consensus was required among researchers on which of the twelve other categories the descriptive text best fit.26 All cases presented at the meeting that were recoded had unanimous agreement among the researchers. As a result, 39 of the responses initially coded as “missed for another reason” were recoded into one of the twelve categories, with eight responses still listed as “missed for another reason.”

Data were analyzed using the IBM® Statistical Package for the Social Sciences (SPSS) version 24 software. Frequencies of reasons for missing the appointment were calculated along with a Chi-Square test of independence for the main reasons that patients missed their appointments. Data were also analyzed by demographic information provided in the EMR by recording frequencies of ethnicity, sex,

Reason Reasons used in related studies by referenceCarlsenet. al.13

Caseyet. al.8

Herricket. al.23

Potamitis et. al.24

Samuels et. al.25

Spikmans et. al.26

Zailinawati et. al.27

I forgot about it x x x x x x xThere was a scheduling error x x x x x x xI was too sick or tired to come x x x x x xI had a family situation or emergency x x x x x

I could not get off work x x xI did not have a way to get there x x xI was not happy with the prior care I received x x

I didn't think I needed the appointment x x x x

I could not afford to pay for the appointment x

I was too anxious/scared to come to the appointment x

I missed because of another reason/ unknown x x x x

Table 1. Reasons Patient Miss Scheduled Appointments and Source(s) of Reason Categories



one of the twelve reasons. As such, the study investigators met to discuss recoding these responses into the proper categories where possible. To support measurement adequacy, consensus was required among researchers on which of the twelve other categories the descriptive text best fit.26 All cases presented at the meeting that were recoded had unanimous agreement among the researchers. As a result, 39 of the responses initially coded as “missed for another reason” were recoded into one of the twelve categories, with eight responses still listed as “missed for another reason.”

Data were analyzed using the IBM® Statistical Package for the Social Sciences (SPSS) version 24 software. Frequencies of reasons for missing the appointment were calculated along with a Chi-Square test of independence for the main reasons that patients missed their appointments. Data were also analyzed by demographic information provided in the EMR by recording frequencies of ethnicity, sex,

insurance type, and disability status (defined as whether the patient was receiving disability benefits). Patients were also stratified into these demographic groups for analysis. Age was recorded and a range and mean for all subjects calculated. Patients were also grouped into age categories of 18-29, 30-44, 45-64, and 65 years and older, a method of grouping used by the clinic system and that would allow for a chi-square of independence analysis.

ResultsThe range of ages of study participants was from 18 to 79 years with a mean age of 51.47 years. Seventy of the patients (74.2%) identified as female and 27 (27.8%) as male. The sample characteristics are presented in Table 2. The patients were mostly Caucasian (81%) followed by African American (10%), Hispanic (5%) and Native American/Alaskan Native (3%). Slightly more than half (58%) had commercial insurance including Aetna, Blue Cross and Blue Shield, Healthchoice, Pacificare,

Tricare, and United Health Care. A third of the patients (33%) reported that they were insured through Medicare and a small number indicated they were insured by the state Medicaid program (4%) or through multiple insurers (5%). Most (90%) were not tobacco users or had quit and a small percentage (11.5%) identified as disabled. Wednesday was the most-frequently missed appointment day (28.4%), followed by Thursday (20.0%), Tuesday (17.9%), then Monday and Friday (both at 16.8%).

Examination of data revealed variability in the reasons respondents’ provided for missing appointments. The most frequently reported reasons included “there was a scheduling error” (21.6%) and “I was too sick or tired to come” (20.6%). The least cited reason was “too anxious/scared to come to the appointment” (1%). During the course of this study, no significant weather issues (such as snow, ice, or severe weather) arose, thus there were no responses to the reason “the weather did not permit me to

come.” Further, none of the patients gave the reason “I started feeling better” as a response. A complete breakdown of the literature-informed reasons patients listed for missing appointments is provided in Table 3.

A Chi-Square test of independence was performed to examine the relationship between reasons for missed appointments and several key demographic variables (ethnicity, sex, age, type of health insurance, and disability). There were no significant differences between ethnicity(χ2 (10) = 6.981, Fisher's exact p=.796) or sex (χ2 (10) = 3.539, Fisher's exact p=.959) and the reasons for appointments missed. There were some significant differences among age group (χ2 (30) = 53.864, Fisher's exact p<.005). People in the 18-29 age range reported higher rates of transportation issues and viewing the appointment as not needed compared to the predicted values. Those in the 30-44 range had higher rates of being unable to get off work as well as

n (%) n (%)Gender Insurance Status

Male 27 (27.80) Yes 93 (95.00)

Female 70 (74.20) No 4 (4.10)

Highest Grade Completed Insurance Type

Less than high school 3 (3.09) Commercial 56 (57.70)

High school/GED 12 (12.36) Medicare 32 (33.00)

Some college 4 (4.11) Medicaid 4 (4.10)

College degree 5 (5.14) Multiple 5 (5.20)

Not reported 73 (75.3)

Disability Status Ethnicity

Yes 11 (11.50) White 79 (81.30)

No 86 (88.50) African American 10 (10.40)

Tobacco User Hispanic 5 (5.20)

Yes 8 (9.90) Native American 3 (3.10)

No 89 (90.10)

Table 2. Characteristics of Participants (n=97)



higher rates of being too scared or anxious, compared to predicted values. Those 65 and older had higher rates of being too sick or tired and lower rates of being unable to get off work than predicted values. The results are presented in Table 4.

Reasons for missing appointments were also examined by insurance type and significant differences were found (χ2 (30) = 44.277, Fisher's exact p<.05) (Table 5). Those with private insurance were more likely to report being unable to get off of work at higher than expected rates, whereas respondents receiving Medicare reported that they were unable to get off work at lower than expected rates. Those patients receiving Medicaid were more likely to report transportation problems. No differences were found when examined by disability.

Patients of all demographic strata (ethnicity, sex, age, insurance type, and disability status) experienced scheduling error as a problem. Of these errors, half were reported to be the clinic’s mistake. Of those, the most frequent was that the patient moved the appointment and the clinic did not remove it from the schedule. The other half of the scheduling errors were reported by the patients as their mistake – with the most frequent being writing down the wrong day, date, or time. In both situations, 89.1% indicated that they did receive an

appointment reminder from the clinic. Reasons categorized as “Missed for Another Reason” accounted for 9 percent of responses. Of these, half were unique and disparate (examples include “too much going on right now,” “began pain management”) and the remaining half pertained to failed communication related to decisions made with the physician. In one instance the patient did not set the appointment, the physician’s office did, but this was not communicated to the patient. In the other three cases, the patients’ physicians discontinued care without informing the physical therapy clinic of the decision.

DiscussionOur survey response rate of 54.8% was consistent with a study by Glass et al., who reported a rate of 50.4% for willingness to participate in telephone surveys.27

Native Americans and people of Asian and Hispanic descent were underrepresented when compared to the population of the Midwestern state in which this study occurred. Moreover, females were over-represented (71.6%) in the sample; however, it has been demonstrated that women are more amenable to participating in telephone surveys than men.27 With this demographic information in mind, data analysis showed no significant differences between ethnicity

or sex with missed appointments. This finding is different from other research that reported males missed more frequently.10,28 and studies reporting greater missed appointments by African Americans23 as well as those of Hispanic/Latino and Native American origin.29 These differences from previous studies may link with the atypical demographics of our sample, even though it was randomly selected.

Findings from this study showed that people who had private insurance missed more appointments than those receiving Medicare or Medicaid. This is also different from multiple studies that have reported increased missed appointments by people on public insurance.30-32 Additionally, more people who were older missed appointments than younger patients, which is counter to what has been reported by other studies.10,31-32

Wednesday was the most frequent day of the week for missed appointments, which was also reported by Chariette and colleagues.4 However, Torres et al. reported more missed appointments occurred on Mondays and Fridays, which was the least-often missed day in this study.10

The top four reasons accounting for 68% of missed appointments were: “scheduling error” (22%), “too sick/tired” (21%), “family

Reason Frequency PercentI forgot about it 8 8.2There was a scheduling error 21 21.6I was too sick or tired to come 20 20.6I had a family situation or emergency 12 12.4I could not get off work 12 12.4I did not have a way to get there 6 6.2I was not happy with the prior care I received 2 2.1I didn't think I needed the appointment 2 2.1I could not afford to pay for the appointment 4 4.1I was too anxious/scared to come to the appointment 1 1.0I missed because of another reason 9 9.3I started feeling better 0 0.0

Table 3. Main Reason Patients Missed Appointments

Notes: *zr ≥ 1.96; †zr ≥ 1.545



or sex with missed appointments. This finding is different from other research that reported males missed more frequently.10,28 and studies reporting greater missed appointments by African Americans23 as well as those of Hispanic/Latino and Native American origin.29 These differences from previous studies may link with the atypical demographics of our sample, even though it was randomly selected.

Findings from this study showed that people who had private insurance missed more appointments than those receiving Medicare or Medicaid. This is also different from multiple studies that have reported increased missed appointments by people on public insurance.30-32 Additionally, more people who were older missed appointments than younger patients, which is counter to what has been reported by other studies.10,31-32

Wednesday was the most frequent day of the week for missed appointments, which was also reported by Chariette and colleagues.4 However, Torres et al. reported more missed appointments occurred on Mondays and Fridays, which was the least-often missed day in this study.10

The top four reasons accounting for 68% of missed appointments were: “scheduling error” (22%), “too sick/tired” (21%), “family

Reason Frequency PercentI forgot about it 8 8.2There was a scheduling error 21 21.6I was too sick or tired to come 20 20.6I had a family situation or emergency 12 12.4I could not get off work 12 12.4I did not have a way to get there 6 6.2I was not happy with the prior care I received 2 2.1I didn't think I needed the appointment 2 2.1I could not afford to pay for the appointment 4 4.1I was too anxious/scared to come to the appointment 1 1.0I missed because of another reason 9 9.3I started feeling better 0 0.0

Table 3. Main Reason Patients Missed Appointments

18-29 Years 30-44 Years 45-64 Years 65+ YearsI forgot about it Count 0 2 2 4

Expected 0.8 1.8 2.9 2.4There was a scheduling error Count 2 6 7 6

Expected 2.2 4.8 7.7 6.3I was too sick or tired to come Count 0 2 7 10†

Expected 2 4.4 6.9 5.7I had a family situation or emergency Count 2 1 4 5

Expected 1.3 2.8 4.4 3.6I could not get off work Count 2 6* 4 0*

Expected 1.3 2.8 4.4 3.6I did not have a way to get there Count 2† 0 4 0

Expected 0.6 1.4 2.2 3.6I was not happy with the prior care I received Count 0 1 0 0

Expected 0.2 0.5 0.7 1.8I didn't think I needed the appointment Count 2* 0 0 1

Expected 0.2 0.5 0.7 0.6I could not afford to pay for the appointment Count 0 0 3 0

Expected 0.4 0.9 1.5 0.6I was too anxious/scared to come to the appointment Count 0 1† 0 1

Expected 0.1 0.2 0.4 1.2I missed because of another reason Count 0 3 4 0

Expected 0.9 2.1 3.3 0.3I started feeling better Count 0 0.0

Expected

Table 4. Main Reason for Missing Appointments by Age Groups

Notes: *zr ≥ 1.96; †zr ≥ 1.545

situation/emergency” (13%), and “couldn’t get off work” (12%). The most frequent reason of “scheduling error” is consistent with the findings of previous studies.5,11,23 Half of the scheduling errors were a result of the patient writing down the wrong time of the appointment, even with eight out of 10 reporting they received a telephone reminder from the clinic. Studies by Liu et al. and Arora et al. reported that text messages when used in conjunction with telephone reminders, decrease missed appointments.33-34

Changes in clinic operations may help to decrease the frequency of missed appointments. Clinic scheduling errors, along with “couldn’t get off work” comprise a

third of all reasons the patients in this study missed their appointments and can directly be addressed by the clinic. To remedy this and given the ease of accessing the scheduling system, when a patient calls to cancel or move the appointment, the clinic could remove the patient from the schedule while the patient is on the phone. Moreover, the clinic could consider expanding its hours so that patients who cannot be released during the typical work day of 8:00 a.m. to 5:00 p.m. can receive care.35

Additionally, changes in the clinic’s scheduling practices may influence missed appointments. It could adopt a system of open access, which is based on

studies showing that the longer the time frame between when a patient makes an appointment and the date of the appointment increases the likelihood of a missed appointment; as such, patients could be given the opportunity to come to the appointment on the day they call to make it.9-10,36-38 Huang and Hanauer demonstrated that overbooking – scheduling more patients to the same time slot – is a successful means of decreasing lost revenue due to missed appointments in medical clinics,39 a finding that was also demonstrated in physical therapy practices by Creps and Lotfi.40

What these studies did not examine were



Private Medicare Medicaid MultipleI forgot about it Count 4 4 0 0


Expected 12.1 6.9 0.9 1.1I was too sick or tired to come Count 9 9 0 2

Expected 11.5 6.6 0.8 1I had a family situation or emergency Count 5 6 1 0

Expected 6.9 4 0.5 0.6I could not get off work Count 11† 0* 0 1

Expected 6.9 4 0.5 0.6I did not have a way to get there Count 2 2 2* 0

Expected 3.5 2 0.2 0.3I was not happy with the prior care I received Count 1 1 0 0

Expected 1.2 0.7 0.1 0.1I didn't think I needed the appointment Count 1 0 1 0


Expected 2.3 1.3 0.2 0.2I was too anxious/scared to come to the appointment Count 1 0 0 0

Expected 0.6 0.3 0 0.1I missed because of another reason Count 5 4 0 0

Expected 5.2 3 0.4 0.5

Table 5. Main Reason for Missing Appointments by Payer Source

Notes: *zr ≥ 1.96; †zr ≥ 1.547

the effects on patient satisfaction or the ethical considerations of this practice. Working with patients to provide them an understanding of the health care system to change their attitudes have also been shown to be effective.2,5,13 Each of these potential approaches to adapt to patient schedules and needs have both benefits and drawbacks.41

A small but notable portion of missed appointments were due to lack of communication with physicians, with the most frequent being the physician discontinuing the patient’s therapy without notifying the clinic. Using the electronic medical record to communicate changes in the patient’s care could lead to enhanced communication between physicians and physical therapists.42 Audit logs that are available within most EMR systems can

also help to identify and resolve these gaps in communication.43

A number of the reasons for missed appointments collected during the study raise questions. Of note: What family situations or emergencies arose? Did additional barriers beyond those of the clinic’s hours exist that caused the person to be unable to get off work? What were the transportation issues? What factors were associated with being unable to afford the care? Why were some patients too anxious or scared? Qualitative notes taken during the process of collecting information from the patients in this pilot study suggest that some of the decision-making factors associated with missed appointments might be related to social determinants of health including family and life stress, physical and

mental health issues, or possibly adverse childhood events (ACEs). Miller-Cribbs and colleagues found that access to health care was significantly related to higher levels of reported ACEs, though this study did not specifically address the relationship between ACEs and missed appointments.44 Although the knowledge generated from these studies is quite compelling, it does not illuminate whether and how ACEs may influence an individual’s choices or ability to make it to health care appointments. To that end, the next iteration of this study will incorporate survey questions related to family stress, mental health, and the presence of adverse childhood events. It will also target more diverse clinic settings and a much larger sample.



Limitations

Albeit a pilot, sample size is one of this study’s limitations along with the demographics of the sample in which females were over-represented and some racial and ethnic groups were underrepresented. Diagnosis codes also were not captured as in previous studies. The study didn’t collect information about the time between when appointments were made and the actual appointment, which has been shown to affect missed appointments.9-10 Phone interviews may be less effective for collecting information than other methods, including on-line or mail survey.27 Potential for recall bias also exists.

Although it involved standardization via the survey form and training of surveyors, variability still existed among those collecting data. Further, the scheduling software that generated the reports for cancellations and no-shows had limited parameters for what constituted a cancellation. In some instances, it was the clinic that moved the date or time of the appointment that resulted in a cancellation being recorded. As this study moves from pilot to full implementation, these factors will be addressed, along with the aforementioned expansion of the survey to capture additional psychosocial data. An electronic version of the survey also will be implemented to enhance the efficiency of data collection and provide real-time information and analysis for use by the clinics. Clinic support staff may be recruited to conduct the surveys as a part of their current work responsibilities for calling patients to schedule or reschedule their appointments. Given the brevity of the survey and the efficiency of an on-line platform that links with the current system, the additional time required in the phone call will be minimal and at no additional cost for the staff ’s time.

ConclusionMissed appointments can have a negative influence on clinic productivity by way of lost revenue and may also negatively influence patient outcomes because the patients don’t receive the care they need. This pilot study

surveying a random sample of patients who cancelled or did not arrive for a physical therapy clinic appointment provides preliminary insight into the reasons why missed appointments occur. The findings of this study begin to illuminate opportunities for quality improvement or business practice changes. For instance, some of the reasons for missed appointments suggest potential courses of action such as altering clinic scheduling processes and expanding hours of operation. Others, such as transportation issues, might prove to be more challenging in how they are addressed. Greater insights can be gained by expanding the survey to include questions related to additional socioemotional factors and spanning a broader array of providers and practice settings.

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Private Medicare Medicaid MultipleI forgot about it Count 4 4 0 0


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Expected 11.5 6.6 0.8 1I had a family situation or emergency Count 5 6 1 0

Expected 6.9 4 0.5 0.6I could not get off work Count 11† 0* 0 1

Expected 6.9 4 0.5 0.6I did not have a way to get there Count 2 2 2* 0

Expected 3.5 2 0.2 0.3I was not happy with the prior care I received Count 1 1 0 0

Expected 1.2 0.7 0.1 0.1I didn't think I needed the appointment Count 1 0 1 0


Expected 2.3 1.3 0.2 0.2I was too anxious/scared to come to the appointment Count 1 0 0 0

Expected 0.6 0.3 0 0.1I missed because of another reason Count 5 4 0 0

Expected 5.2 3 0.4 0.5


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35. Humphreys L, Hunter AG, Zimak A, O'Brien A, Korneluk Y, Cappelli M. Why patients do not attend for their appointments at a genetics clinic. J Med Gen. 2000;37(10):810-815.

36. Mieloszyk RJ, Rosenbaum JI, Bhargava P, Hall CS. Predictive modeling

to identify scheduled radiology appointments resulting in non-attendance in a hospital setting. 39th Annual Int Conf IEEE Eng in Med and Bio Soc. 2017; 2618-2621. DOI: 10.1109/EMBC.2017.8037394.

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38. Nan L, Serhan Z, Kulkarni VG. Dynamic Scheduling of Outpatient Appointments Under Patient No-Shows and Cancellations. Manufact Serv Op Mgmt. 2010;12(2):347-364.

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Appendix 1. Missed Appointments Survey Question Categories with Follow-up QuestionsWhat was the main reason that you missed or canceled your appointment?I started feeling better.

I forgot about it.– Did you write the appointment down? Yes No– Do you keep a calendar? Yes No– Did you receive a reminder call from us? Yes No– How did we contact you? (postcard, email, text, phone)

There was a scheduling error.– The clinic made an error:

o Did we contact you to make a change? Yes No– The patient made an error:

o Did you write the appointment down? Yes Noo Do you keep a calendar? Yes Noo Did you have the right date/time? Yes Noo Did you receive a reminder from us? (postcard, email, text, phone)

I was too sick or tired to come. – Were you hospitalized? Yes No– Were you sleeping at the time? Yes No– Have you been diagnosed with a mental illness such as depression or anxiety disorder? Yes No

I had a family situation or emergency. – I did not have anyone to watch or pick up my child.– I was caring for someone else.

I could not get off work. – Could you have come another day/time? Yes No

I did not have a way to get there. – How long does it take you to get to the clinic? _____ min– Can you drive? Yes No– Did you get lost looking for the clinic? Yes No– How do you usually come to the clinic?

o I drive my carn Is your car in working order? Yes Non Did you have enough money for gas? Yes No

o Someone usually drives me in their car.n Who usually drives you? (friend, relative, volunteer, other)

o I take a city busn How far away is the bus stop? ____milesn How long did you wait for the bus? _____minn Do you use the lift program? Yes Non Did you have enough money for bus fare? Yes No

o I take a taxi or Ubern Did you have enough money for fare? Yes No

o I ride a bicyclen Is your bike in working order? Yes No

o I walk

It was the weather. – What was the weather on the day of the missed appointment?

o It was nice.o It was too hot. o It was too cold. o It was too windy. o It was raining. o It was snowing or icing.

I was not happy with the care I received. – Did you trust the therapist? Yes No– Did you have difficulty communicating with the staff? Yes No– Did they ask if you had questions? Yes No– Did they listen to you? Yes No– Was your diagnosis explained to you? Yes No– Were you involved in making decisions about your care? Yes No– Was your privacy respected? Yes No– Did the therapist seem knowledgeable and experienced? Yes No– Did you have to wait too long? Yes No– Did your treatment cause discomfort or pain? Yes No– Was the therapist clean and hygienic? Yes No– Was the clinic dirty or disorganized? Yes No

I did not think I needed the appointment. – Did another provider refer you to the provider of this appointment? Yes No– Did someone else make the appointment for you? Yes No

I could not afford to pay for the appointment. – Do you have insurance? Yes No– Do you have Medicaid? Yes No– Were you charged for your missed appointment? Yes No – Are you aware we can make alternative pay arrangements? Yes No

I was too anxious/scared to come to the appointment. – Did you agree that you needed the appointment? Yes No– Were you afraid what you might find out? Yes No– Did you comply with previous instructions? Yes No– Did you take your medications? Yes No– Did you fear criticism or rebuke from your provider? Yes No– Are you generally fearful or anxious about medical encounters? Yes No– Have you been diagnosed with a mental illness such as depression or anxiety disorder? Yes No

I missed because of another reason. ________________________

Have you missed other appointments for this reason? Yes No

16

ABSTRACT

Physical Therapy Journal of Policy, Administration and Leadership Vol 18 Issue 4

A Model for Measuring and Clarifying Staff Expectations Following Organizational Restructuring in Rehabilitation Services, with Applications in Management and Workforce Development

Ana Lotshaw, PT, PhDBaylor Scott & White Institute for Rehabilitation

Baylor University Medical CenterDallas, TX

Mary Thompson, PT, PhDTexas Woman’s University

School of Physical TherapyDallas, TX

Ana Lotshaw, PT, PhD // Mary Thompson, PT, PhD

Corresponding Author:Ana Lotshaw, PT, PhD

Baylor Scott & White Institute for Rehabilitation

Baylor University Medical Center Department of Physical Medicine and

Rehabilitation3500 Gaston Ave, Basement Truett

Dallas, TX [email protected]

PRACTICEADMINISTRATION

Study Design. Mixed methods.

Objectives. To determine employee expectations of the work environment following changes in organizational structure, and to translate those responses to system leadership for strategic planning and initiatives.

Background. Mergers and restructuring can have positive or negative effects throughout an organization and decision makers need to be aware of how their workforce is adapting.

Methods and Measures. Therapists from a comprehensive rehabilitation system participated in an online survey with open-ended questions about expectations about their recently restructured organization. Responses were coded using a qualitative inductive process to develop frameworks of themes. A small group of leaders responded to these frameworks for relevance of the responses.

Results. Planned comparisons of themes showed similarities across 140 respondents regarding expectations of themselves and co-workers about the provision of quality care, fairness from the department, and system support of their employees. Thirteen leaders confirmed the value of communication and recruitment, validated steps taken to improve staff development, and identified unmet needs for millennials, high achievers, and longer tenured employees.

Conclusion. Leaders’ understanding of their workforce’s expectations is important in successful staff development, effective communication, and strategies for recruitment and retention. This model may be beneficial for organizational learning to build a shared vision and retain an engaged workforce following organizational restructuring.

Approval. Study approved by Institutional Review Board, Baylor Research Institute, Baylor University Medical Center.

Acknowledgments. For their support of this project, the authors would like to acknowledge Brian Hull, PT, DPT, MBA, Director of Rehabilitation, BSWIR-BUMC, and Simon Driver, PhD, Director of Research, BSWIR.

Vol 18 Issue 4 Physical Therapy Journal of Policy, Administration and Leadership 17Physical Therapy Journal of Policy, Administration and Leadership Vol 18 Issue 4

BackgroundIn this era of changing healthcare environments and U.S. regulatory changes leading to cost containment, organizations must look for ways to remain viable.1 One course of action is for organizations to undergo restructuring to control costs, improve quality, and expand services. However, the perception of workplace instability can negatively affect the rehabilitation professional’s career satisfaction and desire to persist in the job or profession.2 Consumerism permeates all areas of society including both healthcare delivery and employment relationships.3 Consumer models indicate that individuals’ expectations of a product or service (in this case, the workplace) may influence their level of satisfaction and ultimately their intention to remain in that workplace. Therefore, it is in the organization’s best interest to prioritize employee expectations to develop an engaged workforce and create a positive work experience. These efforts may create an overall environment that promotes satisfaction, staff retention, and quality of care. The greater the retention rate, the more cost savings to the organization for new employee recruitment, hiring, and onboarding.4

Employers also have expectations of their employees that are often communicated through job descriptions to define roles, responsibilities, credentials, and competency for a given position. Health care organizations also may communicate structured systems for career advancement by implementing clinical ladders. Together, job descriptions and clinical ladders are standards against which employers recruit, assess competency, and codify practice. Organizational expectations may not always coincide with employee expectations that may vary on individual characteristics such as sex, generation, discipline, tenure, and roles and responsibilities. What is unknown is if expectations of the professional rehabilitation workforce are congruent with organizational expectations. This knowledge gap is important to address when one considers Psychological Contract Theory’s premise that understanding the

beliefs of both parties in employment situations is important for success.5 Within management literature, there is no evidence specific to rehabilitation professionals. The rehabilitation workforce is important to society as a whole; therefore, it is important for healthcare organizations to understand the work expectations of these professionals and use this information for strategic workforce planning. To understand how this applies to a specific organization, we must first describe the environment and events that led to the conception and implementation of this study.

Faith-based, not-for-profit Baylor Healthcare System implemented a joint venture with Select Medical Corporation, a publicly traded for-profit rehabilitation-oriented entity, to form what is now known as Baylor Scott & White Institute for Rehabilitation (BSWIR) in 2011. At the time of this study, BSWIR was comprised of eight hospitals, five inpatient rehabilitation facilities, and 29 outpatient clinics with about 700 rehabilitation professionals.

The purposes of the joint venture were to increase patient access to a branded rehabilitation system in the Dallas-Fort Worth region and improve financial stability, while maintaining the highest quality patient-centered care. This joint venture brought administrative and leadership changes, yet all three organizations remained aligned in terms of missions and values. Clinical operations, documentation systems, productivity standards, clinical ladders, and access to in-house education changed rapidly. However, the shift in workplace culture and identity required a longer transition. After a period of substantial change, we believed it was time for organizational learning by investigating employee expectations in this relatively new system.6 While organizational learning theory typically explains how organizations learn about and adapt to their external environments,7

we decided to use a qualitative method to explore employee expectations as a means for BSWIR to learn about, and potentially

adapt, to their internal environment.

The study was not designed to capture the effects of organizational change or assess employee satisfaction. Rather, its aims were to describe staff expectations within the joint venture rehabilitation system and consider how knowledge of them could be put to future use. Thus, we carried out this study with two purposes. The first purpose was to describe rehabilitation therapist expectations of the work environment across multiple settings and by employee characteristics likely to influence organizational decisions. The second purpose was to determine alignment of resulting expectations with organization leadership. To conclude the study, BSWIR leadership used the results to consider how the information could influence future organizational decisions related to operations, employee development programs and current recruitment and retention strategies.

Methods The Institutional Review Board (IRB) of Baylor Scott and White Research Institute approved this study. The general procedures were based on a process of communicating expectations used at Texas Woman’s University School of Physical Therapy. Details of the methods are described in two sequential phases based on the purposes of this study (Appendix 1).

Phase 1:

The target population included all rehabilitation professionals employed at BSWIR between October 2012 and September 2013. Professions included physical and occupational therapists and assistants; therapeutic recreation therapists; speech and language pathologists; and neuropsychologists. The one-time anonymous online survey was administered using Psychdata® (IRB compliant platform). Participants indicated consent before beginning the two-part survey. The first part, demographic information, would form the basis of the planned comparisons of self, co-workers, department and system

A Model for Measuring and Clarifying Staff Expectations Following Organizational Restructuring in Rehabilitation Services


expectations gathered from the second part via four author-derived open-ended questions (Appendix 2). For example, de Waal and associates report that many researchers believe that age or generational cohort can influence someone’s attitude or commitment toward work with resulting impacts on organizations.8 Similarly, we have noticed different views among those with different careers paths and academic or clinical attainment. Therefore, the planned analyses included seven respondent characteristics based on the literature: four attribute variables (generation, discipline, practice setting, job responsibilities), and three author-defined variables (clinical/academic achievement, organizational tenure, and new professional). We chose

author-defined variables concerning achievement based on the premise that those with more post-professional accomplishments would have different expectations than those who did not seek advancement above that needed to maintain licensure.

Based on the literature, a relationship exists between work motivation and tenure, the passage of time within a person’s specific employment context.9 Riza et.al found that in addition to age, organizational tenure had a role in job satisfaction and may influence employee expectations.10 We believed that expectations may vary with tenure because employees within their first two years of BSWIR employment may not be fully acculturated, whereas

those with > 15 years of service are. To explore the influence of acculturation on expectations among BSWIR’s rehabilitation professionals, we defined two groups that varied on organizational tenure: those new to BSWIR (< two years) regardless of age or time in discipline, and long-standing employees (> 15 years).

Tenure is not synonymous with years in practice. While job challenges contribute to a sense of achievement, research indicates that new professionals may be overwhelmed and need support for the experiences they will encounter in practice to stay engaged in their work.11 Therefore, we thought new professionals may have different expectations from the other respondents. New professionals were defined as

Domain (Attribute Variables)GenerationN = 138*

DisicplineN = 140

Practice SettingN = 140

Job ResponsibilitiesN = 140

3 groups:Boomers(1946-1964)(n = 32)

Generation Xers(1965-1989)(n = 70)

Millennials(1982-1989)(n = 36)

3 groups:PT(n = 90)

OT(n = 38)

SLP(n = 12)

3 groups:Acute care(n = 26)

Inpatient rehabilitation (IPR) (n = 34)

Outpatient(n = 80)

3 groups:Primary patient care (n = 100)

Mixed patient care and manager or administrative duties (supervisor job code)(n = 14)

Primary management/ administration (clinical manager, director, VP, CEO)(n = 26)

Table 1. Domains of Interest Used in Qualitative Planned Comparisons of Respondent Expectations

Domain (Author-defined Variables)Clinical or Academic AchievementsN = 140

New ProfessionalN = 35

Organizational TenureN = 63

2 groups:Yes – those therapists with advanced certification or post professional degrees (n = 4)

No – no advanced training above that of maintaining licensure (n = 136)

1 group:< 5 yrs clinical practice

2 groups:< 2yrs with organization (n = 4)> 15 years with organization (n = 19)

Within each domain, groups were compared on respondent expectations consisting of 4 elements: Self, Co-workers, Departmental leadership, and System leadership

* 2 respondents did not disclose age, PT- physical therapist; OT- occupational therapist; SLP- speech language pathologist; VP- administrative vice president; CEO- chief executive officer



employees with less than five years of experience in their discipline. While there is no uniform timeframe for what constitutes a new professional, this definition has been adopted by the American Physical Therapy Association (Scharan Johnson, Director of Membership Development, e-mail communication, August 25, 2017).

The survey was available for three weeks with reminders given at local staff meetings by staff therapists and an email reminder from the office coordinator to avoid any appearance of coercion.12 New hires in the target professions were surveyed at the time of their new employee orientation.

Data Analysis

Following closure of the survey, we imported demographic and written responses to Microsoft Excel 2010™ for initial data management. We used SPSS® to quantitatively describe the sample, compare the sample to the workforce population, and test for differences via chi-square analysis based on the planned comparisons.

To ensure qualitative dependability and conformability, we independently constructed codes from the raw data. After coming to an agreement over the initial 25% of the data, we independently coded the remaining data. To ensure consistency we reviewed all coding. All data and codes were entered into NVivo8© software for further analyses (word counts and word clouds) and reviewed for common themes. We sorted qualitative data by variables of interest (Table 1) and themes were imported to Wordle™ to verify results in a second word cloud. We determined the four most frequent key word/phrase for each variable and constructed data tables for the next phase of the study.

Phase 2:

In January 2016, we invited all current BSWIR managers, directors and administrators to participate in the study’s next phase. We chose leaders for this single-session exercise to represent the leadership as a whole, and for their influence on the organization’s decisions and direction. Since

time had lapsed since phase 1, we reoriented the group to the study’s purposes and methods and provided detailed quantitative and qualitative results. To effectively manage the group, we purposefully divided leaders into three equal-sized small groups to maintain diversity in practice settings and discipline and to enhance discussion among the leaders.13 The intent of the author-moderated focus group was to understand the phase 1 results from the perspective of the leaders by: 1) discussing the face validity of the results; 2) providing their perceptions about the results in the current 2016 workforce, answering the following question: “Do the results still hold true?”; and 3) identifying potential applications of the results to recruitment, retention, staff development and general operations.

Concluding the session, we reconvened BSWIR leaders into a larger group to discuss further the range of perceptions and conclusions that emerged. We facilitated discussions, clarified data, if necessary, and recorded comments. BSWIR leaders provided demographic characteristics for later description.

Phase 1 ResultsThe anonymous survey was closed in September 2013, with 156 responses, a 22% response rate. While we surveyed all rehabilitation disciplines, physical therapist assistants, certified occupational therapist assistants, recreational therapists, and neuropsychologists were removed from analysis because only 16 responded and their practice setting would reveal their identities. Consequently, we only used data from physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) in the final analysis yielding 140 respondents. Furthermore, the number of new hires was not sufficient for meaningful comparison purposes to the established workforce.

Respondent Characteristics

Basic respondent characteristics for the entire sample are reported in Table 2.

Overall, respondents were similar to the BSWIR PT/OT/SLP population at the time of the survey. While PT and SLP respondents were relatively over and underrepresented respectively, differences were not statistically significant (χ2=5.3, df=2, p=.070). In contrast, when describing the respondents by setting, therapists were overrepresented in the outpatient setting and underrepresented in acute care (χ2=27.2, df=2, p <.001).

When examining respondents by setting, they were disproportionately distributed (χ2=13.6, df=4, p=.01) across practice settings with PTs more predominate in outpatient clinics and few OTs in acute care. No SLPs from acute care responded to the survey. Among all respondents, there were no significant differences among the disciplines for years in practice and years within the organization. Regarding tenure at BSWIR by practice setting, acute care therapists had the longest tenure at BSWIR (mean=10.2 years), whereas outpatient and inpatient rehabilitation therapists had similar tenures of 5.7 and 5.6 years respectively (p < .05). Among new professionals (those in practice < 5 years), the majority were in their first year of practice (42.9%). Within the outpatient setting, there was a disproportionate number (p<.05) of therapists with <1 year of practice compared to either the IPR or acute care settings. There were 19 long-standing employees (>15 years) at BSWIR who were on average 50.8 years of age with 25 years of practice.

Job responsibilities were defined by respondents’ primary duty within the organization and as expected, age and experience increased with job responsibility. At the lowest tier, primary patient care duties, the mean age was 38.6 years, with 11.9 years practice experience. The highest tier, primary manager/administrator had a mean age of 45.7 years with 19.8 years of practice experience. At this highest level, the ratio of males to females was equal, whereas females held a significantly greater proportion at other job levels.

In summary, the typical respondent was a Generation X (born 1965-1981) female, 40.2 years old. She was a PT in the outpatient



Respondents (N = 140) Focus Group (N = 13)Mean (SD) f

Age (years)Male (n = 27)Female (n = 123)

40.2 (11.1)44.1 (11.8)39.4 (10.8)

SexMaleFemale

49

Years in Practice 13.9 (10.6) Years in practice0-1011-1516-20>20Missing

03451

Tenure at BSWIR (years) 6.5 (7.6)

Percentage of SampleGeneration

Boomers (n = 32)Generation Xers (n = 70)Millennials (n = 36)

23.750.425.9

DisciplinePT (n = 90)OT (n = 38)SLP (n = 12)

64.327.18.6

DisciplinePTOTSLPAdministration

8221

Practice settingAcute care (n = 26)Inpatient rehab (n = 30)Outpatient (n = 80)

18.624.357.1

Practice SettingAcute CareInpatient rehabOutpatientAdministration only

6421

New professional Discipline

PT (n = 28)OT (n = 4)SLP (n =3)

Practice setting Acute care (n = 23)Inpatient rehab (n = 6)Outpatient (n = 6)

80.011.48.6

65.817.117.1

Years in management0-56-1011-1516-20>20Missing

413212

Job responsibilities1° patient care (n = 100)Mixed patient care/manager(n = 14)1° manager/administrator(n = 26)

71.410.0

18.6

Clinical or academic achievement Yes (n = 4) No (n = 136)

2.997.1

Table 2. Participant Characteristics by Role in the Study

SD = Standard Deviation; PT = Physical Therapist; OT = Occupational Therapist; SLP = Speech Language Pathologist



setting and had on average 13.9 years of practice, and 6.5 years of service at BSWIR. The typical respondent’s primary role was patient care and she had not sought advance training above licensure maintenance.

Respondents’ Expectations

Responses to open-ended questions focused more on workplace culture and organizational relationships rather than task-specific or daily operations details. Four primary themes emerged from the data: 1) communication, 2) best patient-centered practice, 3) quality and excellence, and 4) support from leaders and the system. Only the frequency in these themes varied within domains or across groups. In general, respondents’ expectations of self (Table 3) and co-workers (Table 4) were to provide quality, patient-centered care. Respondents had the same expectations of their co-workers as they had of themselves including meeting job expectations. They expected communication, fairness, and employee support including education, equipment and technology resources from the department (Table 5) and system (Table 6). It appears that front-line therapists did not differentiate between the “department” and the “system,” whereas the supervisor group had more specific expectations at both the department and system levels. In addition, long-term (>15 years) employees and respondents with high clinical or academic achievement desired educational opportunities beyond entry-level skills/knowledge from the system. Unique to millennials (born 1982-1989) and new professionals (most of whom were millennials in the outpatient setting), was the frequent expectation that the department keep current with technology, which was not identified by other groups. Millennials and new professionals also expected the system to focus on improving the strategic brand marketing of the organization.

Phase 2 ResultsThe discussion group consisted of 13 BSWIR clinical managers or above (Table 1). This group valued employee responses across all of the planned comparisons and came to a consensus that 2013 responses were

consistent with the leaders’ perceptions of the 2016 workforce. Furthermore, they thought employee responses were aligned with Baylor Scott & White Health, Select Medical and the organization’s mission and values. Leaders discussed the application of employee responses in relationship to current recruitment efforts. They suggested seeking candidates that matched current employee expectations and including these expectations as part of the behavioral interviewing process. Leaders also confirmed that steps taken since the survey to improve staff development (in-house education and clinical ladder) were aligned with employee expectations and would aid in retention of the new professional. However, leaders also identified continued gaps in meeting the needs of high achievers and longer tenured employees with the goal of retaining these valued employees. Regarding operations, leaders valued employees’ responses regarding communication and acknowledged that this was an on-going issue being addressed at the department and system level.

DiscussionIn a changing healthcare environment, organizations must remain keenly aware of their financial well-being and their workforce vitality. It is in an organization’s best interest to retain good employees, but the reasons people stay and contribute to an organization are more complex than job satisfaction alone. Frequently organizations ask employees about job satisfaction leading to information that may reflect extrinsic factors such as compensation and benefits. However, an employee’s expectations are derived from intrinsic factors such as beliefs, experiences and perceptions of performance.3,14 These concepts are separate but related in that expectations can drive satisfaction. These factors play important roles including the symbiotic alignment of values between the organization and individual.11 This study was designed to describe the expectations of employees in a rehabilitation healthcare system independent of job satisfaction. What was unknown was if the expressed

expectations were aligned with and reflected the organization’s values, and if so, whether leaders could incorporate them into its modes of operation and future initiatives.

BSWIR was willing to ask what employees expected rather than conducting a traditional satisfaction survey that assumes expectations. The resulting four common themes were not surprising as they were aligned with organizational values and mission, but we anticipated more diversity among the compared groups. The fact that most respondents were PTs in outpatient clinics may have skewed results. Meanwhile, as the joint venture matured, leaders took steps in terms of operations and staff development independent of this study. Presenting the results to leaders gave them the opportunity to assess if the steps taken since the joint venture were aligned with employee expectations.

How can these expectations be applied to BSWIR’s strategies for recruitment, retention and staff development? Regarding recruitment, organizations try to prevent a “wrong hire” to avoid detrimental side effects including disruption of the working environment of other employees. Knowing what established employees expect of their co-workers can help in the selection of new employees that not only align with the organization’s mission, but also enhance the organization’s strengths and minimize weaknesses.16,17 Having used behavioral interviewing as part of employee selection for a number of years, BSWIR can actively seek responses and behaviors consistent with current employee expectations from prospective hires. Another organizational benefit of knowing employee expectations when hiring staff are the relationships among expectations, job fit, and satisfaction first described by Locke and Lawler back in the 1970s.16,17 One might think that these relationships are linear: meet expectations, match job fit, and satisfaction improves. However, dissatisfaction occurs when job reality is below the expectation of the employee.18 Awareness of employee expectations can serve as a bridge between

SD = Standard Deviation; PT = Physical Therapist; OT = Occupational Therapist; SLP = Speech Language Pathologist



recruitment and retention.

Retention involves both extrinsic and intrinsic factors that motivate an individual to stay in an organization. Addressing extrinsic factors such as compensation, benefits, and work schedules were outside the scope of this study. However, extrinsic factors related to current technology and brand-marketing expectations are factors that leaders could keep in mind for future initiatives and growth. The results of this study focused on intrinsic factors with practical opportunities for staff support and

development. As BSWIR leaders considered these expectations, they identified the in-house continuing education and clinical ladder as two recent programs that would meet or exceed the expectations of 1) educational opportunities and 2) support from department and system. In-house continuing education was started to have more frequent, accessible, and cost-effective education that was broader in scope available to staff for their own development and in support of system initiatives. The expanded clinical ladder was developed for non-management rehabilitation therapists

that ranged from staff therapists to advanced clinical specialists. Although voluntary, employees could elect to use the ladder to further their own development and improve their skills. Both of these programs demonstrated organizational support that empowered employees to use best practices and provide quality and excellent care.

Strategies for recruitment, retention, and staff development are enhanced by taking into account current employee expectations. Failure to do so risks potential misalignment. Therefore, readers should

Generation Discipline Practice Setting Job ResponsibilitiesBoomers 1. quality, excellent care 2. meet expectations3. professionnalism4. enhance workplace

Generation Xers 1. quality, excellent care2. ethical3. professionalism4. teamwork

Millennials 1. best, excellent care2. team player3. professionalism4. efficiency

OT1. best, quality, excellent care2. team player3.EBP4. respect

PT1. best, quality, excellent care2. professionalism3. compassion4. teamwork

SLP1. professional2. excellent care3. EBP4. meet expectations

Acute care1. best, quality, excellent care2. compassion3. help others4. professionalism

IPR1. best, quality, excellent care2. improve function3. professionalism4. team work

Outpatient1. best, quality, excellent care2. improve function3. professionalism 4. teamwork

Primary patient care 1. best, quality, excellent, efficient care2. improve function3. professionalism4. teamwork

Mixed patient care and manager or administrative duties (supervisor)1. best, quality, excellent care2. put patients first3. lead4. communicate

Primary management/ administration 1. best, quality, excellent care2. ethical3. help others4. efficient care

Table 3. Expectation Results by Domain: SELF

Clinical or Academic Achievements New Professional Organizational TenureYes1. different aspects of “care” quality, excellent, skilled patient centered2. relationships involving leadership, helping others, respect, empathy

No 1. best, quality, excellent, efficient care2. improve function3. professionalism4. ethical

< 5 yrs clinical practice 1. best, quality, excellent care2. improve function3. teamwork 4. professionalism and growth

< 2 yrs with organization1. best, quality, excellent care2. professionalism 3. improve function4. ethical

> 15 years with organization1. best, quality, excellent, efficient care2. make a difference3. improve function4. provide care to best of abilities

PT = Physical Therapist; OT = Occupational Therapist; SLP = Speech Language Pathologist; IPR = Inpatient Rehabilitation;EBP = Evidenced-Based Practice



exercise caution in generalizing these specific expectations to different situations. For example, research in nursing and medicine demonstrate different motivators in regards to recruitment and retention.19 However, other healthcare systems could replicate the methods used in this study to explore the expectations of their employees and develop their own strategies.

Previous literature also has emphasized the importance of effective communication20,21 for overall organizational health. According to organizational learning theory,22 an “open

dialog” about differences in expectations can serve as the catalyst for improvements, teambuilding, and a shared vision within the organization. Asking about expectations may be daunting to leaders, but is essential to verify that their workforce is aligned with organizational missions and values. Consistent with Psychological Contract Theory,5,22 mismatches in expectations may lead to employee dissatisfaction, especially if leadership fails to acknowledge, discuss, and actively address these differences.

BSWIR therapists also expected effective

communication. Based on these results, we encourage organizational leaders to evaluate the expectations of their workforce and openly talk about any misalignment. In doing so, BSWIR leaders can create positive work environments to 1) develop and motivate employees to give the highest level of care, and 2) establish longevity to promote and sustain future growth and successorship.19

The first step in managing expectations is to make them mutual and explicit from recruitment through annual reviews and career advancement. Leaders can take the













Table 3. Expectation Results by Domain: SELF


Generation Discipline Practice Setting Job ResponsibilitiesBoomers 1. high expectations of others as themselves2. work as a team3. meet job expectations4. professionalism

Generation Xers 1. best quality care2. respect3. work as a team4. meet job

Millennials 1. help each other2. respect3. professionalism 4. best care

OT1. same as self2. best, excellent care 3. meet job expectations 4. work as team

PT1. work as team2. meet job expectations3. respect4. best quality care

SLP1. same as self2. work as team 3. quality of care4. respect

Acute care1. same as self 2. respect3. best, quality, excellent care4.collaborate

IPR1. best care2. work as team3. meet job expectations4. professionalism

Outpatient1. same as self2. meet job expectations 3. best, quality, excellent care 4. work as team

Primary patient care 1. same as self 2. respect3. professionalism 4. work as team, help each other

Mixed patient care and manager or administrative duties (supervisor)1. work as team 2. quality best care 3. meet job expectations4. communicate

Primary management/ administration 1. meet job expectations2. same as self 3. ethical 4. quality, excellent care

Table 4. Expectation Results by Domain: CO-WORKER

Clinical or Academic Achievements New Professional Organizational TenureYes1. work as a team2. help each other3. dependable 4. ----

No 1. same as self2. best, quality, excellent care3. respect4. meet job expectations

< 5 yrs clinical practice 1. same as self2. help each other/teamwork3. best care4. professionalism

< 2 yrs with organization1. best, quality care2. same as self3. professionalism4. work as team

> 15 years with organization1. same as self2. work as team3. quality care4. meet job expectations

PT = Physical Therapist; OT = Occupational Therapist; SLP = Speech Language Pathologist; IPR = Inpatient Rehabilitation;EBP = Evidenced-Based Practice; ; ---- no predominate expectation after those listed



next step by identifying areas that they can modify or manage based on the employees’ expectations. Adoption or revision of employee development programs can provide a means to manage expectations in more cost-effective ways. This process can lead to better employee engagement and awareness, increased motivation and satisfaction and ultimately longer retention in the organization.23

One limitation of this study is that the expectations were defined by those who

responded to the survey. We believe our results may be representative of BSWIR therapists because they match the known workforce in terms of gender, discipline and setting. In addition, BSWIR’s workforce was relatively stable with retention rates of 77% to 100% across the system for the four years during and following the study. Another limitation is the low response rate. While our overall response rate is within one standard deviation of survey responses in organizational research

(35% ± 18%),15 we also had low numbers of younger therapists and new hires. One possible reason could be that we traded leadership-endorsed mandatory participation for volunteered anonymous responses in hopes of increased candor about expectations.12 Perhaps respondents (acculturated employees) felt they had a vested interest in the study’s outcome and therefore responded at a higher rate than newer employees. Nevertheless, it benefits the organization to know that their more














Table 5. Expectation Results by Domain: DEPARTMENT








(35% ± 18%),15 we also had low numbers of younger therapists and new hires. One possible reason could be that we traded leadership-endorsed mandatory participation for volunteered anonymous responses in hopes of increased candor about expectations.12 Perhaps respondents (acculturated employees) felt they had a vested interest in the study’s outcome and therefore responded at a higher rate than newer employees. Nevertheless, it benefits the organization to know that their more


tenured employees remained aligned to the organization’s mission and values.

This group’s responses also highlighted opportunities. Leadership became aware of some different expectations that represented continued gaps of certain groups. Long-tenured rehabilitation professionals and those who obtained clinical/academic achievement are at different points in their careers and have different needs than the new professional just beginning a career. For example, an early BSWIR clinical ladder

provided a structured system of professional development for new therapists based on practice experience alone that did not meet the needs of the long tenured advanced clinician. After the survey, BSWIR launched a new clinical ladder that supports a wide range of professional development opportunities such as specializations and post-professional education that can be customized to the needs of the advanced clinician. The findings of the study support the decisions made by leadership prior to

the focus group to change the ladder. The current ladder supports the different needs expressed by the new professional and long-tenured advanced clinicians in our study.

ConclusionSeveral conclusions can be drawn about this rehabilitation organization and its employees. First, we found that following the joint venture, it is possible to sustain foundations of an organization’s culture













Table 5. Expectation Results by Domain: DEPARTMENT






Generation Discipline Practice Setting Job ResponsibilitiesBoomers 1. communicate 2. support3. guidance4. fairness

Generation Xers 1. support employees2. communicate3. provide equipment4. provide educational opportunities

Millennials 1. provide educational opportunities 2. communicate3. market brand4. provide equipment

OT1. provide educational opportunities2. provide equipment3. communicate4. market brand

PT1. support employees2. provide educational opportunities3. communicate4. market brand

SLP1. communicate2. support staff and leaders3. fiscal responsibility 4. market brand

Acute care1. place employees first/ support 2. place patients first 3. respect4. ----

IPR1. communicate2. provide equipment3. provide educational opportunities4. support employees

Outpatient1. provide educational opportunities2. support employees3. market brand4. promote growth

Primary patient care 1. provide educational opportunities2. communicate3. provide equipment4. support employees

Mixed patient care and manager or administrative duties (supervisor)1. support employees2. fix communication issues3. value, respect, appreciate employees4. communicate

Primary management/ administration 1. support employees2. same as department 3. communicate4. trust

Table 6. Expectation Results by Domain: SYSTEM

Clinical or Academic Achievements New Professional Organizational TenureYes1. provide educational opportunities2. communicate 3.----4.----

No 1. provide educational opportunities2. support employees 3. communicate 4. same as department

< 5 yrs clinical practice 1. provide educational opportunities2. market brand3. communicate4. support employees

< 2 yrs with organization1. provide educational opportunities2. provide equipment3. market brand4. communicate

> 15 years with organization1. support employees2. provide educational opportunities3. same as department 4. communicate



in the midst of significant change. This was demonstrated by a close alignment of employee expectations and organizational mission remained. Second, even in a complex and diverse work environment, there are more similarities than differences among rehabilitation professions’ expectations regardless of individual characteristics. This finding allows leaders to use a generalizable approach when considering expectations during program development and strategic planning. Finally, while the results may not be generalized beyond this rehabilitation organization or licensed rehabilitation professionals, these methods may be used by other healthcare organizations as a first step to build a shared vision and retain an intrinsically motivated engaged workforce.

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21. Schafer DS. Three perspectives on physical therapist managerial work. Phys Ther. 2002;82(3):228-236.

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23. Berg JL. The role of personal purpose and personal goals in symbiotic visions. Front Psychol 2015; 6:443. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396129/. Accessed November 18, 2017.


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Project Design(Month 0-6)

December 2011

• Conceptionalized workplace project based on academic model presentation• Discussed concept with acute care department leadership • Established collaboration with TWU/BIR• Designed project; developed survey; chose participant characteristics, target

population; and wrote consent letter and methods for survey deployment. • Obtained IRB approval.

Survey(Month 7-14)

• Launched survey across system for 3 weeks via email and announcements made at staff meetings

• Made survery available to new employees at system orientation• Closed survey

Analysis(Month 15-31)

• Analyzed quantitative data (demographics and characteristics)• Analyzed qualitative data:

• Executed planned comparisons based on literature and reserachers' work and academic insights

• Coded comments and identified common themes in each category: self, co-worker, department, and system expecetations

• Developed visual and written frameworks

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Consensus(Month 31-33)February 2015

• Presented initial results to system leadership via small group discussions• Facilitated consensus of framework by system leaders• Solicted feedback on results and its application to the current workforce• Dissemenated results and recommendations

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Appendix 1. Methods Timeline


Descriptive Characteristics Open-Ended Questions• Age• Sex• Position held:

staff, proficient, senior, supervisor, or director/manager, VP or above (based on current clinical ladder and job description titles)

• Discipline• Type of facility:

AcuteInpatient rehabOutpatient services

• Years of service with BIR • Years of practice • Entry level degree• Country of entry level degree• Highest degree attained• Recognized certification or board certification of specialization in discipline

“In your position at BIR, what are your expectations of yourself?”

“In your position at BIR, what are your expectations of your co-workers?”

“In your position at BIR, what are your expectations of your department?”

“In your position at BIR, what are your expectations of your system?”

Appendix 2. Online Survey Contents


Join Us in D.C.

Global Health

SIGThe Catalyst

Global Health SIG ReceptionFriday, Jan. 25 | 8:00 p.m.-10:00 p.m.

TENATIVE LOCATION:Marriott Marquis Salons 7-10

Washington, D.C.

Are you attending CSM 2019 and interested in global health initiatives? Want to support your Section? Join HPA The Catalyst and its Global Health Special Interest Group (GHSIG) for our annual GHSIG Reception! Immediately following the HPA The Catalyst Membership Meeting on Friday, Jan. 25, the reception allows therapists

with a passion for helping those globally to connect with one another and with companies who also support these international iniatives.

Physical Therapy Journal of Policy, Administration and Leadership Vol 18 Issue 4

Official Publication of the Section on Health Policy & Administration of the American Physical Therapy Association

2400 Ardmore BlvdSte 302Pittsburgh, PA 15221p: 1-877-636-4408www.aptahpa.org


Join Us in D.C.

Are you attending CSM 2019 and interested in global health initiatives? Want to support your Section? Join HPA The Catalyst and its Global Health Special Interest Group (GHSIG) for our annual GHSIG Reception! Immediately following the HPA The Catalyst Membership Meeting on Friday, Jan. 25, the reception allows therapists

with a passion for helping those globally to connect with one another and with companies who also support these international iniatives.

december 2018 vol. 18 // no. 4 · ffe physical ffierapy journal of policy, administration and...

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