November 2005

In Pursuit of (Clinical) Excellence

By Nicole B. Matoushek, MPH, PT, CEES

Implementing a system of core values and ethics in one’s practice is good for business

It is an exciting time for the physical therapy profession. We have been provided with an opportunity to demonstrate our clinical and professional excellence by practicing with autonomy and providing high-quality care with financial accountability.

The industry trends, including the transition toward the DPT and direct access, require therapy professionals to improve their clinical management strategies while continuing to practice under the virtues and codes inherent to the profession. Professional and clinical excellence can be reached in autonomous practice with adherence to the professional core values, standards of practice, and ethical guidelines.

CORE VALUES IN CLINICAL PRACTICE
Core values in clinical practice are inherent to the therapy profession. Therapy practice involves the integration of clinical skills and clinical management strategies to achieve a common goal: To provide medically necessary care in a manner in which the provider's, the patient's, and the payor's goals and perspectives are all respected. Practicing with core values will assist the clinician to achieve this common goal.

The seven core values that best reflect the most important elements of professionalism in physical therapy practice are: Accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility.¹ Adherence to these seven core values of professionalism will ensure the delivery of high-quality and medically appropriate services in which all parties' perspectives are respected.

These seven core values require the therapist to demonstrate accountability by responding to the patient's and the payor's needs and providing only medically necessary care. The therapist must provide a treatment plan that reflects the individual needs of the patient. The therapist must provide safe and appropriate treatments with the highest degree of clinical excellence. The therapist must demonstrate high levels of knowledge and skill in all aspects of the profession, including clinical knowledge as well as skill in clinically managing the delivery of therapy services. The therapist must practice with integrity reflected by the adherence to the regulations, laws, codes, and guidelines established by the APTA, reimbursement schedules, and state institutions. The therapist must practice professional and social duties by promoting their professional and social responsibilities. This includes providing only medically necessary care and ensuring economic efficiency by requesting remuneration for only medically necessary care through the services that are provided. In summary, in order to achieve the highest levels of professionalism, the therapy professional must provide clinical management and services that are in accordance with all of these core values.

STANDARDS OF PRACTICE
The APTA Standards of Practice for Physical Therapy states that "the physical therapy profession is committed to providing an optimum level of service delivery and to striving for excellence in practice."² The professional practices that are essential for the provision of high-quality therapy focus on the development and modification of the treatment plan based on the medical necessity of the individual patient. The standards of practice require of the therapy professional that the therapy services that are provided include a plan for the continuous improvement of quality of care and performance for all patients. The therapist must provide evidence of ongoing review and reevaluation of the services that are being provided. The therapist must develop a plan of care that is based on the diagnosis, prognosis, anticipated goals, and expected outcomes. This plan should be individualized and based on medical necessity.

In addition, the treatment plan should be modified in terms of intervention, visit frequency, and duration in accordance with the response to treatment and any changes in status. Finally, the therapy professional should discharge or discontinue skilled therapy services when the patient has obtained the established goals, has reached a level of function in which they may continue to progress and no longer require the supervision of a therapist, or will no longer benefit from the therapy services. The therapy services that are provided should have purpose and goals that reflect the needs and interests of the individual patients and clients that are served. High levels of professionalism require adherence to these standards of practice guidelines.

CODE OF ETHICS
The APTA developed its Code of Ethics in order to guide the physical therapist in matters of professional conduct and to promote ethical practice. There are several key principles that are essential to the provision of high-quality and appropriate services. First, the physical therapist shall exercise sound professional judgment. Second, the therapist shall achieve and maintain professional competence. Third, the physical therapist shall maintain and promote high standards for practice. Last, the physical therapist shall seek only such remuneration as is deserved and reasonable: the therapist shall avoid the overutilization and the underutilization of therapy services.

In all situations, the therapist should make ethical professional judgments and direct treatment plans and remuneration based on medical necessity for the skilled therapy services that are determined according to the individual patient's needs.

CLINICAL MANAGEMENT STRATEGIES
Strategies in the clinical management of skilled therapy can be applied in autonomous practice in order to ensure that the skilled therapy services are compliant with professional standards. Some of these clinical management strategies include: Ensuring patient responsibility, providing therapist-driven treatment plans, avoiding over- and under-utilization, and providing a positive, goal-directed environment in skilled therapy.

PATIENT RESPONSIBILITY
The first clinical management strategy to ensure professional and clinical excellence in skilled therapy is to see that patients take responsibility for their active participation in the rehabilitation process. Patient responsibility and getting the patient independent from the need for further skilled therapy should be a primary goal. The patient should be instructed and educated in the disease or injury process, the prognosis, and the development and implementation of the treatment plan. The patient should be instructed in an independent home exercise program and injury protection concepts in order to facilitate healing and prevent aggravation to the injury. The patient should be made aware that compliance with this education is critical for their recovery.

Achieving this goal requires an active approach in managing the skilled therapy care. If a passive clinical management approach is taken, potentially, the patient may believe that they need the therapy intervention in order to get better. This belief creates a patient who is dependent on the system. To achieve clinical and professional excellence in autonomous practice, the therapist must actively encourage and require patient responsibility and independence in their own rehabilitation.

THERAPIST-DRIVEN TREATMENT PLANS
The second management strategy in achieving clinical and professional excellence is to provide therapist-driven treatment plans. Based on the profession's values, standards of practice, and ethics, the objective of skilled therapy service provision is to deliver only medically necessary treatments as efficiently and effectively as possible. This objective is the pinnacle of therapeutic professionalism. However, this objective can be achieved only when the therapist actively manages the treatment intervention based on the medical necessity of the individual patient. Clinical management should involve the development and modification of the therapy treatment plan that is based on the individual characteristics of the injury and the patient, the prognosis, the anticipated goals and outcomes, and the patient's response to treatment. Modifications of the treatment interventions may include altering the therapeutic techniques and/or the visit frequency and duration of services.

At times, the ordering physician may direct the treatment plan by indicating the therapy treatment, frequency, and duration. If the therapist strictly adheres to the prescribed orders as opposed to modifying the treatment plan based on the medical necessity of the individual patient, potentially, the treatment that is provided may not necessarily reflect the treatment plan that is optimal for the individual patient. Ultimately, the over- or under-utilization of therapy services may occur, as the treatments rendered may not necessarily reflect the true medical necessity of the individual patient.

In autonomous practice, the treating therapist is the expert in the rehabilitation of the patient. The treating therapist directs the treatment plan based on the medical necessity for each individual patient. The end result is more efficient and effective therapy treatments, as the plan of care is determined by a professional who not only is educated and trained in skilled therapeutic theories and practices, but also has practical hands-on experience in skilled therapy provision. Achieving clinical and professional excellence requires therapist-driven treatment plans.

AVOIDING OVER- AND UNDER-UTILIZATION
The over- and/or under-utilization of skilled therapy services may occur if the therapist adopts a passive role in clinically managing the therapy services. This goes against the core values and the APTA code of ethics. Overutilization may result if the patient is not responsible for their rehabilitation or becomes dependent on the therapist to make them better, if the therapist does not modify the treatment plan based on the medical necessity of the individual patient, or if there is financial incentive in receiving remuneration based on the services that are provided. In addition, under-utilization of therapy services may occur if the therapist does not actively manage the therapy services based on the needs of the individual patient. The end result is therapy services that may not necessarily reflect the true medical necessity of the individual patient.

Therapy service delivery should abide by the APTA code of ethics in that it should not involve the under- or over-utilization of therapy services. As illustrated, passive clinical management may potentially inhibit the therapist from achieving clinical and professional excellence. Clinical and professional excellence requires active clinical management and the adherence to the therapy profession's core values, standards of practice, and code of ethics. The delivery of only medically necessary treatments results in professional excellence and autonomy, and should be encouraged and rewarded.

POSITIVE, GOAL-DIRECTED ENVIRONMENT
The fourth clinical management strategy in achieving clinical and professional excellence in autonomous practice is to provide a positive and goal-directed environment in therapy. This therapy environment will help to keep the patient motivated and progressing forward with the rehabilitation plan of care. Fostering a positive and goal-directed environment requires active clinical and professional skill and effort on the part of the treating therapist. There are a variety of methods to help provide the patient with positive and goal-directed care.

First, provide goal-directed treatment plans that are discussed with the patient at the time of the initial evaluation, during the course of therapy, and at the time of discharge. Goals should be measurable and developed in a manner that the patient can understand. Therapy activities should relate to the goals so that the patient is aware of forward progress or a need for improvement. This provides the patient with feedback and keeps the patient motivated and on target. The action of discussing the goals with the patient establishes clear expectations for the patient, informs them of progress, as well as facilitates compliance. Additionally, the patient will be better prepared for discharge when they are aware of the goal status and the progress made in therapy.

Second, the therapist should provide direction regarding the patient's compliance with attending therapy visits and performing the home exercise program. This requires ongoing effort on the part of the therapist to encourage and motivate the patient as well as educate them on the importance of attending regularly scheduled visits and participating in a home exercise program.

Third, provide a rehabilitation staff that offers continued encouragement, respect, and support. This is inherent to the profession's core values. These values can be demonstrated if the therapist has an appreciation of the mental, physical, and emotional resources and states of the individual, as some patients may have experienced a loss in function, social activities, and work activities or are coping with pain. Providing understanding and compassion for each individual's experience will help to provide a positive, therapeutic environment.

Next, emphasize active therapy techniques as opposed to passive therapy techniques. This creates an environment that fosters active patient participation and functional restoration as opposed to dependence on modalities and passive therapy activities.

Last, encourage consistent and appropriate behaviors while providing behavior modification techniques that are supportive and professional as opposed to confrontational. These clinical management methods will assist the patient in making forward progress in obtaining the skilled therapy goals while ensuring clinical and professional excellence in a positive therapeutic environment.

Clinical and professional excellence can be achieved when the clinician adheres to the profession's core values, the APTA Standards of Practice, and its Code of Ethics guidelines. To achieve clinical and professional excellence in autonomous practice, the therapist must take an active role in clinically managing the skilled therapy. This means the therapist should encourage and require patient responsibility, direct the treatment plan based on the medical necessity of the individual patient, request remuneration that is deserved and reasonable, and provide a positive, goal-directed environment for rehabilitation. Adherence to these practice guidelines promulgates the delivery of medically appropriate care and services, keeps the patient moving forward toward therapy goals, and takes the profession to a whole new level.

Nicole B. Matoushek, MPH, PT, CEES, has more than 12 years of collective clinical, ergonomic and utilization review experience in physical therapy services. She is president of ErgoRehab Inc, and can be reached at www.ergorehabinc.com.

REFERENCES

1. Bezner J. Getting to the core of professionalism. PT Magazine. 2004; 12(1):25-27.
2. Standards of Practice for Physical Therapy. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001.
3. Guide for Professional Conduct/Code of Ethics. Alexandria, Va: American Physical Therapy Association; January 2001.

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