Autonomous Practice Through Staff Empowerment

Vision 2020 calls for autonomous practice in physical therapy. Staff empowerment may be one important step toward achieving that goal.

By Chris Hayhurst

When Stephen Anderson, PT, talks about autonomy-as in autonomous practice, a linchpin of APTA's Vision 2020-he gets excited. He uses words like “progressive” and “visionary.” He stresses concepts like “leadership” and “ownership.” And most of all, he offers ideas on how to get there and how to reach the point at which physical therapists (PTs), as he puts it, “can use their education and intellect to make decisions not only in terms of patient care, but also in terms of their profession.”

Anderson, CEO of Washington-based Therapeutic Associates, Inc, and president of APTA's Private Practice Section, should know. He's done it himself, and now, as leader of the very company with which he first signed on out of school, he's helping others do the same. His basic approach: staff empowerment. “The more you empower someone, the more they feel like the work is as much theirs as anyone else's,” explains Anderson. “And only good things can come from that.”

APTA's Vision 2020

Good things, of course, already are here for both physical therapists and physical therapy as a profession. Consider this: Almost 6 years ago, in 2001, APTA developed its Vision Statement 2020. Among other things, the document states: “Physical therapists will be practitioners of choice in clients' health networks and will hold all privileges of autonomous practice.”¹ An autonomous physical therapy practice, as defined by APTA, is characterized by independence, self-determination, and professional judgments and actions. Similarly, a physical therapist who is practicing autonomously serves patients who have unrestricted access to those services and can refer to other health care professionals when necessary.²

“Autonomy can mean different things to different people,” says Mary Pat Corrigan Jobes, PT, MA, president of APTA's Acute Care Section and administrative director of rehab services at Methodist North Hospital in Memphis, Tennessee. “At our facility”-multidisciplinary and primarily inpatient-“autonomy means collaborative practice. It means you're respected for your skills and there's an understanding of what you do.”

As of early 2007, 43 states nationwide permit some level of direct access. According to Dave Mason, APTA's director of government affairs, three more states are likely to pass direct access legislation before the end of the year. “Direct access,” says Mason, “is important as far as achieving the overall vision of the Association and the profession to be appreciated as autonomous practitioners and as recognized professionals. It's really part and parcel of the recognition of what PTs do and the level of education and clinical preparation they go through to be able to provide the kind of care they do.” In other words, as direct access becomes universal, autonomous practice, too, becomes the norm.

So back to Stephen Anderson. As direct access increases, and autonomous practice follows, where do empowered staff fit into the equation? To answer this question, it helps to turn to Kanter's theory,³ which holds that individuals who feel empowered-that is, who have power and opportunity-are happier and more productive at work and are more committed to their jobs and to their organizations as a whole. Empowered staff exhibit independence; they think for themselves and, when appropriate, make decisions without the need for approval.

Sound familiar? It should. Empowerment, while not synonymous with autonomous practice, is a critical element of autonomous practice. One cannot be autonomous without being empowered, yet empowerment requires a certain level of autonomy.

Physical therapists may be empowered in numerous ways. They can be given unfettered access to information, support, and resources, whether it's continuing education, time for attending professional conferences, or the skills to do research. They can be included in organizational meetings and involved in business decisions. When it's time to buy equipment, renovate, or expand, staff can be consulted and asked for their needs, opinions, or input. They can be given respect and responsibility, managed only loosely, and treated as peers by their colleagues. They can be “given a say”-in their health care package, their working hours, and their work conditions. They can be held accountable for their actions and decisions.

Jobes, for her part, provides her staff, which includes 14 physical therapists, “with all the tools they need to perform their jobs.” Often, she says, that includes offering freedom in their schedules, as many staff members work part time. “We try to be very accommodating,” says Jobes. “When people have babies, and they don't want to come back full time, we do what we can to make schedule changes and keep them here. We're pretty flexible. And everybody knows that if somebody is out, they may need to cover, and that when their turn comes somebody else will do the same for them.”

In addition, says Jobes, PTs are encouraged to specialize. “If someone develops an interest in a particular area of care, we try to find a continuing education course or other opportunities for them to enhance his or her skills. He or she then becomes the primary person in that area that people go to with any questions.”

Two Tracks to Success

That strong sense of responsibility among the staff at Methodist North is equally pervasive at Stephen Anderson's Therapeutic Associates. A rehabilitation services company that includes more than 50 PT-owned and directed clinics across the Pacific Northwest, Therapeutic Associates builds empowerment into its business structure. “We do two things here,” says Anderson. “First, we have a leadership development program in which we place every PT who enters our company on a track designed to develop leaders and autonomous practitioners. And then, at the end of that development, they have an opportunity to become owners within the company.”

Anderson says that employees who are not interested in the ownership track needn't worry. They're still welcome. “It's important to realize that actual ownership is not for everybody. In our company, all PTs go through the leadership development program, develop leadership skills, and learn how to improve their business acumen. That way, they become leaders within the clinic, when treating their patients, and doing the things they're good at doing. They develop what I call an 'ownership mentality.' So even if they never exercise that ownership piece, they still have the benefit of learning and growing within our organization.”

A Little Encouragement

Moving practitioners toward autonomy is a major part of Peter McMenamin's job. McMenamin, PT, MS, OCS, is president of APTA's Illinois Chapter. He's also sole owner of Physical Therapy Chicago, Ltd, a three-clinic downtown practice offering a variety of specialty services, including outpatient orthopedics, industrial consulting, women's health, and cancer rehabilitation. Together the clinics employ six physical therapists.

“There are a number of ways I encourage staff empowerment,” says McMenamin. “Number one, we have weekly 2-hour staff meetings where we review cases, discuss articles, talk about the practice, and discuss professional issues. We try to keep a professional dialog going. Second, I encourage them to really understand the state practice act and what it allows us to do. I want them to feel empowered by the act, not limited by it.” In Illinois, for example, PTs can evaluate patients without referrals. “They know what services they are entitled to provide,” says McMenamin.

With a similar goal in mind, McMenamin trains staff to develop confidence in their expertise. “I encourage them to exercise independent judgment-not in a vacuum, but with all the facts in place-even if it contradicts a referring physician's judgment. Then, when they do have clinical opinions that differ from a referral source, we discuss how that can be handled. They learn how to defend their clinical judgment, and how to make it sound to begin with.”

Independence comes gradually. When a new physical therapist starts at one of his clinics, for example, says McMenamin, he'll review all legally important written correspondence before it goes out. Eventually he steps back. “Over time, as they prove they have the ability to exercise that independent clinical judgment, I give them much more room to do things on their own.”

Staff empowerment at Physical Therapy Chicago also is achieved through professional development initiatives, says McMenamin. He encourages PTs to give presentations, for example, and allows them to practice their presentations in the clinic before they head out to the undoubtedly more intimidating audiences at professional meetings and conferences. He also offers financial incentives and other company support for everything from continuing education to transitional DPT studies and clinical specialization.

Helping employees take their careers by storm, says McMenamin, is not without its challenges. “From a bottom line standpoint, it has the potential to build the practice. But if anything it's been hard, because as therapists become much better trained and qualified and get clinical specialization they obviously want to be paid more. Well, the payers don't pay us more when a more qualified therapist is providing the intervention.” A solution, he says, likely will involve providing staff even more room to grow-offering equity ownership in the practice, for example. “My hope,” says McMenamin, “is to create enough opportunity to keep those people here.”

Every Clinician a Manager

That approach, says Stacey Zeigler, PT, DPT, MS, GCS, is exactly the right way to go. When an owner, manager, clinical director-whatever the title may be-opens the doors to professional development, empowerment and autonomy will come naturally, she says.

“You don't have to motivate people,” says Zeigler, clinical assistant professor at Clarkson University Physical Therapy Department and a co-presenter (with Kate Wolske-Brewer), at the 2005 APTA Combined Sections Meeting, on “Human Resource Management for Today's Multidisciplinary Team: Beyond the Basics.” “You do have to provide an environment in which they can flourish. And that goes right along with the concept of empowerment-allowing your colleagues to flourish, even if it's outside your organization. It's our duty as professionals to foster that growth process. And if it happens that that growth path doesn't follow what the department values or the direction in which the facility is going, then that's not the place for them. Then it's a matter of assisting them in finding a different position as opposed to putting limits on what they can achieve and how far they can go. In my mind there should be no limit to empowerment.”

Zeigler, whose management experience includes more than 5 years as assistant administrator of rehabilitation services at Carthage Area Hospital in northern New York, where she supervised a multidisciplinary team of PTs, occupational therapists, speech language pathologists, and nurses, says empowering staff in a public facility like a hospital may require a different approach than that taken in private practice. “People perceive empowerment to be a lot easier in private practice. When you're talking about an organization that dictates, to a certain extent, what you can do for empowerment, and because the culture in your department is part and parcel to the culture of the organization at large, sometimes it's a bigger challenge within a hospital environment to create the workings for autonomous practice.”

Her CSM presentation, says Zeigler, emphasized the need for physical therapy department heads (managers/directors/supervisors/owners) to define themselves as coworkers and facilitators, not as the boss in charge. “It should be 'My colleagues,' not 'my staff,'” says Zeigler. “The management is part of the staff. When we said that, I saw some of the peoples' eyes widen. Some people still think of that position as being one of power. 'I'm in charge, and they have to do what I tell them to do, and it's my job to motivate them' as opposed to 'What can we do to create the environment in which they can do as much as they need to do to grow as a professional and to grow the profession?'”

While health care administrations may stratify management and staff into different categories by varying responsibilities, says Zeigler, a good manager can break from that traditional mold. “The manager of a physical therapy department should not be the powerful boss who spends the day taking complaints, fixing problems, and directing staff as to what they should or should not be doing. The manager is the colleague who has been given the privilege of inspiring, modeling, and creating an environment in which all can thrive.”

Such an environment requires, by definition, a proactive staff. “From a health policy and administration standpoint, it's 'every clinician a manager,'” says Zeigler. True staff empowerment, she says, is achieved in an environment of interdependence and accountability, not dependence. Staff should not depend on management to solve their problems any more than management should depend on staff to solve theirs. “In an autonomous environment, people manage themselves. It's a bunch of professionals who are working together rather than someone being a boss while all the underlings follow along.”

The Power of Passion

That cooperative spirit is something Suzanne Lawrence, PT, understands well. As clinical research educator in the inpatient acute rehab center at Fletcher Allen Health Care in Essex Junction, Vermont, Lawrence wears many different hats. Much of what she does, however, is program redesign-providing guidance and support for clinicians as they incorporate the latest research into either a standard of practice change or alterations in the way a facility program is run. A recent project, she says, involved leading an interdisciplinary team working to unify and standardize Fletcher Allen's spinal cord injury rehabilitation program.

The key to success when it comes to revamping a program, says Lawrence, is involving-that is, empowering-the right people. Inevitably, she says, that means the clinicians, not imported “experts.” “It's really hard when an expert comes in, particularly in their own profession, and says, 'This is the standard, I'm going to give it to you and now I want you to do it.' We're past that point as professionals. We've found it's much more effective to empower the people who are passionate about the pertinent clinical problems. Clinicians really operate from their experience base and their gut.”

Empowerment, says Lawrence, is achieved through a variety of approaches. “One is to have the time and the administrative support to bring a group of clinicians who are passionate about the same problems together. That can happen anywhere-over lunch, at the end of the day, whenever. But when we notice that there's a particular issue that we're hearing a lot about, we'll just call a meeting. When people are passionate about a problem, and they get together and we facilitate an open discussion, pretty quickly what emerges is their energy to take a look at the issues and find solutions. But the beginning key is always just to get the passionate clinicians together, give them a little bit of time, give them support with the right tools and the right resources, and just a basic framework of a vision-and the vision that we have is that any clinical solution that develops will be born out of the evidence.”

Lawrence acknowledges, “In some cases there's not a lot of evidence and it's difficult to define best practice. Then it's the responsibility of the group to find the experts nationally. It's very rare that we look inward and develop something based only on our expertise. We always network.” For those who are interested in becoming project facilitators themselves, says Lawrence, administration provides training (via mentors, for example).

Once the ball is rolling, she says, those involved are supported every step of the way. Clinicians are taught to do literature searches and to interpret research. If necessary, they interview other professionals at model practices. They attend conferences and ask questions. “It's empowering,” says Lawrence. “They're going through the process of defining the problem and finding out that other people are interested in it. They have a tool to help channel their energies. They have an articulated vision from administration that solutions must be based on evidence-based practice. So they have this framework, start the process, and develop solutions. Sometimes they work beautifully and sometimes they fail. But in the end, when the staff put that kind of energy behind a particular problem they care about, and they feel good about the manner and the tools they used to analyze it, they have a high degree of ownership. They've been empowered. And that's where we get results.”
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Chris Hayhurst is a freelance writer.

References
1. Vision 2020. APTA Vision Statement for Physical Therapy 2020. Available at www.apta.org/AM/Template.cfm?Section= Vision_20201&Template=/TaggedPage/TaggedPageDisplay .cfm&TPLID=285& ContentID=32061 . Accessed January 14, 2007.
2. PT Bulletin Online. Definition of Autonomous Practice Adopted. Available at www.apta.org/AM/Template.cfm?Section=Archives2&Template=/Customsource/ TaggedPage/PTIssue.cfm& Issue=03/14/2001#article8076 . Accessed January 14, 2007.
3. Miller PA, Goddard P, Spence Laschinger HK. Evaluating physical therapists' perception of empowerment using Kanter's theory of structural power in organizations. Phys Ther. 2001:81:1880-1888.

_{PT Magazine - April 2007}