What does 90% productivity look like?

By February 17, 2015 Ethics 13 Comments
clock productivity

THIS POST HAS BEEN UPDATED. See most updated post here.

I’ve written about productivity before. Productivity isn’t the problem. The problem is what productivity causes – a focus away from patient care. And yes, I have heard the argument ‘We think patient care is the most important thing too. That is why we want you to spend X% of your time on patient care’.

Unfortunately, we are working in a billing system that doesn’t reimburse for indirect patient care. <-- See what I did there? "Indirect patient care", because things like caregiver education are patient care. However, lawyers, bill indirect services and it still leaves room for many problems,
“Treating legal services as a commodity that can be measured in units of time diminishes the importance of both the quality of the work produced and the results achieved. Few other industries would thrive if they measured productivity by the time their workers spent without regard to what those workers created. The standard invites inefficiency, not to mention fraud.”

Sound familiar?

Efficiency isn’t the name of the game

In graduate school, I remember hearing bits and pieces about productivity expectations (though none of my clinicals were in the SNF setting). I casually thought, “I have always been an efficient worker with good results (in my prior career). Meeting productivity expectations won’t be a problem for me.” Little did I understand. I thought all the time I spent working toward the goals and tasks of my job would be “productive”, because that totally makes sense, right?

As I prepared to talk to people outside our field about ethical concerns, I figured they would have the same ill-informed notion. So I created a document to explain what 90% productivity looks like and what it doesn’t include. I hope this illustration will help students and those outside the field to understand the responsibilities of therapists beyond direct patient care.

What does 90% productivity look like?

90% Productivity for an 8-hour day looks like this:

  • 8 hours = 480 minutes
  • 90% billable time = 432 treatment minutes
  • 10 patients a day means roughly 43 minutes per patient

This example assumes a therapist only spends 3 minutes in between patients, which would be record speed since most buildings I’ve worked in have had 4 wings or floors to traverse. It also assumes that all patients would benefit from the same amount of treatment. Of course, some patients would benefit from more and some from less.

8:00-8:05 Drop personal things off, pick up today’s schedule, gather materials for first patient, walk to patient
8:05-8:48 Patient number 1
8:48-8:51 Transport patient, walk to office, obtain materials for next patient, walk to patient
8:51-9:36 Patient number 2
9:36-9:39 Transport patient, walk to office, obtain materials for next patient, walk to patient
9:39-10:22 Patient number 3
10:22-10:25 Transport patient, walk to office, obtain materials for next patient, walk to patient
10:25-11:08 Patient number 4
11:08-11:11 Transport patient, walk to office, obtain materials for next patient, walk to patient
11:11-11:54 Patient number 5
11:54-11:57 Transport patient, walk to office
11:57-12:27 Clock out for Lunch and bathroom break.
12:27-12:30 Obtain materials for next patient, walk to patient
12:30-1:13 Patient number 6
1:13-1:16 Transport patient, walk to office, obtain materials for next patient, walk to patient
1:16-1:59 Patient number 7
1:59-2:02 Transport patient, walk to office, obtain materials for next patient, walk to patient
2:02-2:45 Patient number 8
2:45-2:48 Transport patient, walk to office, obtain materials for next patient, walk to patient
2:48-3:31 Patient number 9
3:31-3:34 Transport patient, walk to office, obtain materials for next patient, walk to patient
3:34-4:17 Patient number 10
4:17-4:20 Transport patient, walk to office, obtain materials for next patient, walk to patient
4:20-4:30 Document session notes and time to complete unbillable necessary tasks such as:

  • Calling families to update on status and recommendations for discharge planning.
  • Attend care plan meetings with families, nursing staff, social worker, doctor, etc to discuss status and discharge planning.
  • Complete screenings of patients who have been admitted to the building recently, annual screenings, or nursing concerns.
  • Complete evaluations and obtain standardized scores.
  • Write up evaluations, discharge summaries, weekly progress notes, 30 day recertifications, etc.
  • Attend therapy team meetings to discuss status, collaborate to improve patients outcomes, etc.
  • Consult with other professionals (SLPs, social workers, psychiatrists, psychologists, etc) regarding complex patient cases.
  • Write orders updating treatment frequency and duration.
  • Write orders and educate nurses and CNAs regarding diet texture and consistency changes.
  • Obtain patient records from modified barium swallow studies, prior speech therapy, gastrointestinal specialists, otolaryngologists, etc. to update plan of care.
  • Problem solve behavior and communication challenges and train nurses and CNAs to provide appropriate level of cueing and assistance to maximize independence and while maintaining safety.
  • Complete inservice trainings with new staff or current staff at regular intervals to ensure that appropriate referrals are being made and staff is equipped with skills to manage dysphagia and cognitive-communication disorders.
  • Troubleshoot computer and documentation software issues. I have never worked with software that was so buggy as the documentation software used by therapists in SNFs.
  • Copy and prepare materials for therapy. Such as patient education handouts and obtaining food for trials from the kitchen.
  • Supervise graduate student interns or clinical fellows.
  • File paper copies of progress notes, evaluations, recertifications, and discharge summaries in paper charts.
  • Complete company required continuing education.
  • Reading email and written notes from managers (often about failure to meet productivity expectations) or having meetings with managers about failure to meet productivity requirements.
  • Performance reviews and other human resources related activities.

These non-billable tasks are important and make a difference in patient outcomes.

**This schedule does not account for the 10-15 minute paid breaks that many states grant workers for every 4 hour period work. Google “paid rest break” + your state to learn more about your state’s laws.

***Very seldom does a schedule go as smoothly as this schedule. Often a therapist will go to see a patient and they will be in the shower, out for a doctor’s appointment, working with another healthcare professional, visiting with family, refuse, etc. Which means therapists are walking to the patient’s room. Finding they are not there. Then they have to consult with CNAs and nurses to locate the patient. The therapist is unable to see the patient, but spent 10 minutes trying to locate the patient. Then the therapist goes to the next patient. Rarely does a SNF have a schedule for therapy. Therapists are given names and required minutes for the day, and it’s essentially a free for all.

Rachel Wynn
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Rachel Wynn

Speech-Language Pathologist at Gray Matter Therapy
Rachel is a speech-language pathologist and creator of Gray Matter Therapy. She started making noise as a patient-centered care advocate in 2013. She believes great care happens when patients are informed and engaged.
Rachel Wynn
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  • Marina Pawlesh

    Yes and when you are working as a PRN SLP for the day with 90% productivity expectation, you don’t know the patients so you briefly scan the information about the patients before treating, attempt to locate patients in a facility you may not be totally familiar with, attempt to ask other therapists for assistance and don’t get any help because everyone else is trying to stick to their productivity numbers, etc.

  • Eselpee

    First of all, what is the history of calling billable time “productivity”? It implies that the long list following the example schedule above is nonproductive. Call it what it is, “billable time”, and the remainder of one’s day “nonbillable”. Its all productive.

    I no longer transport patients, but pretty much treat where we are. I see my caseload sequentially. If someone is engaged in another activity, the next isn’t far. I can see those I miss on the next pass. This has led to some nice impromptu collaborations.

    I have my pockets filled with most items I need (the NH has very little, anyway). We are immersed in the place where the follow through will occur with the people who will be assisting. I have developed great relationships with the nurses, CNAs, and families. Its been great.

    I pretty much work as efficiently as I can and stick my nose up at “their productivity” numbers. I don’t care; its not ethical. I feel that For Profit NHs are unconscionable. How dare they make a profit at the expense of our elders. What is ASHA (and the nurses, MD’s, OT, & PT national organizations) doing to change this? I am required to sign all sorts of paperwork that I will be ethical – all lip service. The pressure is always present to save the NH money.

  • Daphne Dawson

    Rachel, as always you summed it up perfectly! The only thing you left out was “actually acknjowledge a former (confused) patient who is trying to find the dining room & walk him/her there.” But, heaven forbid!! This is NOT billable time! When I worked in a SNF 12 years ago, even though I was actually employed by a contract therapy company, we were encouraged to feel like we were part of the SNF. I was paid for 8 hours, and when I didn’t have a “full” caseload I assisted CNA’s with activities or helped pass out trays at meals (and would observe residents for signs of increased confusion or difficulty swallowing during this “down” time. I’m back in SNF setting after 8 years & now feel like I can’t make eye contact with anyone for fear of not being productive. Had I known in grad school the choice of horrible settings I would have to work in I would’ve chosen another field. Very sad that our profession has come to this.

  • kathi Boziel

    Hi! I was just reviewing your time line for productivity. I noticed that you clocked in @ 8:00 took a half hour lunch and clocked out @ 5:30. I believe that is 9 hours unless I missed something. That would put your productivity at approx. 80%. Look how busy you were @ 80%!! Productivity is an endless battle between trying to get everything done while providing the best treatment possible for your clients.

    • http://graymattertherapy.com/ Rachel Wynn

      Very delayed, but the math was corrected. Now it’s just impossible.

  • Christine dits

    This is the best post I’ve read here so far, because you just described my day basically, and I don’t feel SO ALONE anymore!! I about 80-90% certain I’ll be looking for a job in another wetting after this SNF CF. I still need to learn more about all this fraud and unethical behavior/activity, but what I’ve read and experienced so far is enough to discourage me… Sadly to say. I’m just very, very happy I’m not the only one feeling this intense pressure! Not to mention having to work off the clock and stay late at times just to finish the paperwork and keep your job!!! It’s ridiculous.

    Thank you for your post!!!

    • http://graymattertherapy.com/ Rachel Wynn

      You are certainly not alone!

      • Tiffany Hannan Citty

        Christine, I am also a CF in a SNF and am experiencing the exact same issues. The company indirectly says do whatever you have to do to maintain productivity including staying off the clock to complete documentation. It’s so frustrating!

  • sad.slp

    I’m curious how this mandate is reconciled when we may consistently observe our staff sitting in the gym for 1/2-1 hour in the morning (while the patients eat their breakfast), another 1/2-1 hour midday (while the patients eat their lunch), and another 1/2-1 hour in the afternoon to wrap up documentation before clocking out. All the while individual treatment is billed, and maybe a bit of concurrent (rarely group because it doesn’t make business sense, right?).

    Is everyone carrying a sick secret? What do the regionals truly believe happens every day in their buildings? Do they really believe that when their staff is 95% productive for the eight hour day, that that actually physically HAPPENED?

    Another interesting perspective that I find is that when therapists fall below the productivity mandate, managers & regionals are quick to write-ups and/or “performance improvement” discussions, whereas if a PRN clocks 99% or 100% productivity for the day…I DO NOT GET A PHONE CALL. If a full-time therapist who is usually 90-93% magically becomes 98% one day…I DO NOT GET A PHONE CALL.

    May the stars align and help us all.

  • tafa

    Or clock in ,keep trying to clock in because your mandatory handheld device doesn’t link, keep trying then put the hand held aside so you can pick up your pt list. Review pt list, try to locate hard copy of pt’s med info, eval, etc. so you know pt’s condition ,precautions and goals. Find pt. Check with nursing in re to meds for pain ,wait for nurse to dispense meds. Provide pt with treatment in over crowded gym with old,broken equipment. Stop to help pt with dementia to find their room make sure staff is aware of said pt’s whereabouts.Move on to next pt ,check room ,activities ,rehab gym for pt .Pt is nowhere to be found; turns out pt had a medical appointment out of building, attend care plan meeting for another pt who has opted not to attend…..

    • http://graymattertherapy.com/ Rachel Wynn

      Absolutely! I don’t know how many times I have looked for a patient that was out of the building. There are so many things we do in a day that are valuable but not billable.

  • Hunter Lane

    I know this is not a forum to complain but are we as therapists ok with what I just looked up? The median salary for cco’s of SNFs according to Google is 750k$ a year for median salary of income?!?! Even if you make a third that at 250k$ annually that 20k$ a mo!!!!!!! Are you kidding me then why are not therapist getting paid way, way, way more money?! Especially if you went to school on the past 5 years for your masters or DPT? I also can’t find what a SNF makes off of one therapist annually what can maintain close to an 80% productivity rate?

  • Pascal’s Wager

    Had a “manager” for a major rehab company tell me my goal in the SNF was 75%. When I consistently hit 80%, it became not good enough and she said it needed to be improved and that I should use our tech more. Being given a title of manager does not make one a good manager and I agree that the push like this “manager” is making is a good way to push people (not me) to fraudulent behaviors.