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  • Too Much Focus on Productivity Increases Risk of Unethical Behavior, Say Researchers

    Employers that overemphasize productivity goals over evidence-based practice (EBP) may inadvertently set the stage for unethical behaviors by physical therapists (PTs) and physical therapist assistants (PTAs), say authors of an unedited new study published ahead of print in Archives of Rehabilitation Research and Clinical Translation. Organizational culture, say authors, is "the most easily changeable" factor in promoting ethical behavior.

    In an email survey, researchers asked licensed PTs and PTAs in the state of Texas about their practice settings, their employers' use of productivity goals, and observed unethical behaviors, such as inappropriately discharging patients or falsifying or changing documentation.

    The majority of the 3,446 respondents were women (70.5%) and had been practicing an average of 15 years. One-third of respondents were PTAs. The most-represented practice settings were skilled nursing facilities (SNFs) (23.1%) and private outpatient clinics (17.7%).

    Their findings include:

    The majority of employers set formal productivity goals. Of the respondents, 73.9% said their employers set productivity goals for them. Of that group, 85.1% indicated that the goal was based on billable units per hour. However, 54.5% said they had no input into the goal-setting process.

    The use of productivity goals varied by setting. SNF clinicians were most likely (97.1%) to report having productivity goals, while school system PTs and PTAs were least likely (13.2%). [Editor's note: an accompanying table in the unedited article includes different percentages.]

    As the rate of expected productivity increased, so did the rate of observed unethical behaviors. Of all respondents, 53.3% indicated their productivity goals were difficult or very difficult to meet, and 60.2% felt they were high or much too high. Most clinicians said that productivity goals influenced their clinical decision making.

    SNFs had the highest prevalence of observed unethical behavior as well as the highest frequency of each behavior. PTs and PTAs in SNFs were 4 times more likely as those in other settings to report having observed unethical behavior.

    Overall, unethical behavior is not widespread. While a majority of respondents had observed unethical behavior, 68.6% reported observing it "rarely" or "never."

    However, workplace cultures emphasizing ethics are not common, either. Only 38.9% of respondents said their organization's culture emphasized ethical practice, far below the business average of 66%.

    Focusing on ethics and evidence-based practice may discourage unethical behaviors. The degrees to which an organization emphasizes ethical and evidence-based practice were negatively associated with observed unethical behavior. Employees whose organizations emphasized productivity over EBP and ethical practice were, respectively, 6 times and 3.39 times more likely to have observed unethical behaviors.

    One of the contributing factors to unethical care is a payment environment that results in patients and clinicians being "disconnected from negative consequences" over overutilization, say authors. They write, "Historically, utilization of rehabilitation has been highly influenced by financial incentives, with significant variances in factors unrelated to caseload such as geographic location and payer source."

    Authors explain that business pressures toward overutilization often are accompanied by a gradual shift in the attitudes of clinicians, who "justify overutilization of rehabilitation services by portraying it as meeting their patients' desires or sustaining their own livelihood." This "moral re-construal" in turn paves the way for unethical behavior, with clinicians and patients seldom experiencing the results of overutilization, given the typical health care system with its long gaps between service delivery and payment.

    Given the ways business decisions can set the stage for unethical behavior, change must take place at the organizational level, which also happens to be "the most easily changeable component," researchers write. Among their recommendations: Survey employees about the ethical climate and organizational behavior; avoid the use of productivity standards based on billable units; and involve clinicians in developing productivity goals.

    "Use of productivity standards measured solely by the quantity of billable units is not advised," authors write. "We recommend that clinicians are involved in the setting of productivity standards."

    APTA members Justin Tammany, PT, DPT, MBA, ScD; and Janelle O'Connell, PT, DPT, PhD, were among the authors of the study.

    The issue of productivity pressures is at the heart of a "Consensus Statement on Clinical Judgment in Health Care Settings (.pdf)" collaboratively created by APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association. For more on productivity, check out "Measuring by Value, Not Volume," in PT in Motion magazine.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.