O'Brien JA

Tearful breakdowns and loud outbursts—they happen with orthopedic patients even in the best of practices. And if you are an orthopedic surgeon who has rarely or never experienced a patient in emotional distress, just talk with your staff—they have no doubt experienced this many times. 

There is something about orthopedic conditions—they carry with them an increased likelihood of emotional adverse effects for patients and their loved ones. Inhibited movement can lead to palpable frustration and depression. Time off from work may cause financial hardship and an identity crisis for a family breadwinner. Physical pain can cause the patient to become depressed, angry, or dependent on prescription medication. Medications can cause a change in disposition or outlook. These realities make orthopedic surgery practices particularly predisposed to patient relations risks and service recovery opportunities.

As a practice management consultant and former executive director of an orthopedic practice, I have observed and participated in patient relations and service recovery efforts at many levels. Particularly proud of the way our staff and physicians prevented and handled these and having spent many years traveling by air under the color-coded TSA (Transportation Security Administration) security level indicator system, I created the Patient Relations and Service Recovery Guide (Figure) to help practices gain perspective, have a vocabulary, and develop practical methods for mitigating patient relations risks and responding to incidents and complaints.

The Patient Relations and Service Recovery Guide

The Patient Relations and Service Recovery Guide shows the relationship between the practice as a whole and the patient as an individual. 

Green and Red

Green describes the elements of service orientation that the practice must consistently demonstrate and convey to each individual from the point of access, through treatment, and, finally, during account settlement. If you think you have a systemic problem with anything under the Green heading, you probably need a practice management or service orientation consultant, not this article. Red shows the other end of the spectrum—a complete degeneration, worst-case scenario.  As with problems in the Green category, this article will not help you in these Red situations, for which you need experienced legal counsel immediately.

We’ll now explore the stories, challenges, opportunities, and practical suggestions for the Blue, Yellow, and Orange categories. The Blue and Yellow categories in the Figure are shaded in grey as a depiction of the interactive, fluid nature of these situations. In addition, they are situations that have developed and can be resolved within and by the practice.

Blue

Patients are very comfortable complaining to the receptionist, x-ray technician, and medical assistant about any number of perceived shortcomings, but when you walk in the examination room, not a word. This is a reality I am sure you have heard about from your staff, and it puts them in a position to observe and determine if a patient’s frustration is escalating. Telephone and front desk receptions are first in line. Patients will say to a telephone receptionist, “I have called 3 times yesterday and twice today and the doctor/nurse still hasn’t called back.” Front desk receptionists will also observe dynamics in the seating area. Staff are your partners in patient relations and service recovery. Working together effectively will help you address issues in the Blue and Yellow areas.

Create an environment that prevents patient discontent and supports service orientation goals. A hospital-based practice that I once managed was a flagship for service excellence goals of a Fortune 150 corporation, had a large seating area, and was close to the airport in a city with multiple company properties; we frequently had executives showing up unannounced, and, because of company politics, it seemed like they were actively looking for instances of substandard service. More importantly, though, we had patients. We established “Waiting Stories” as a performance standard for the receptionists. That is, at any moment, the receptionist was able to recap the “story” of each person in the seating area. The “story” is the reason the person was there, the appointment time, and the cause of the delay, if the wait time was excessive. We all knew this was a performance standard for our practice, so if a receptionist called back to the clinic to find out the reason for a backup in throughput, everyone was respectful and responsive to the inquiry. 

The receptionists quickly became effective in judging situations and mitigating or avoiding breakdowns in service and communication. We also implemented an easy and quick notification code for when they needed help handling a service recovery situation. The responses and support in those situations were unwavering, consistent, and blame-free. We would debrief after a significant situation was resolved to determine if there were systemic or response improvement opportunities.

Communication among staff is essential for preventing or mitigating patient discontent. All practices experience service and throughput errors occasionally: a quiet, uncomplaining patient inadvertently doesn’t get called back and remains in the seating area unnoticed; a call doesn’t get returned; x-ray breaks down and a spine patient has to make a painful walk; the physician has to interrupt the encounter to take an important call; etc. Stuff happens. Individually, these breaches are tolerable to most patients. Unfortunately, there can be a cumulative element—when various service mishaps happen to the same patient. This is when communication and support among the staff and with the manager become especially important. If a patient has weathered a rough or long wait or has expressed some dissatisfaction while in the reception area, it’s probably a good idea to let the back-office staff know, so they can show a little extra compassion and be cognizant of additional situations.

Clinical staff and the physicians must convey support and appreciation to front-line staff who observe and share that a patient may be prone to distress, so that they will continue to participate in active incident prevention and service recovery. 

Heightening awareness on the part of your staff—especially, receptionists, technicians, medical assistants, and collectors—goes a long way toward getting patient discontent issues settled before they get out of hand. As executive director of a large orthopedic surgery practice, I was particularly proud of our staff’s sensitivity to patient discontent, their sense of when it might be helpful to bring in a manager, and the managers’ ability both to recover many situations and to know when it was most effective to get help and support from either one of the executive team or physicians.

I can remember one patient that both front-line staff and the manager determined needed some service recovery intervention. She had been visibly upset at the end of her final postoperative visit with the physician. The staff noticed and called the manager in. The patient mentioned to the manager that she had been to another orthopedic surgeon who had told her that the surgery our physician had performed was not the right one and that he would have done things differently. The patient said she just didn’t know what to do. Our manager had the keen sense to know that she should get help to recover the situation within our practice. She and all of the staff were always supported when they asked for help, and the physicians were good about expressing their gratitude to the staff for their efforts. The manager escorted the upset patient to my office where we talked—well, she mostly talked and I listened. It turned out that her injuries had prevented her from attending games during her only child’s senior soccer season. I know, it sounds more like therapy—it was a lot of listening and compassion on my part. Eventually, she got around to thanking me for listening. And while that was not the end of it (there was another conversation), she did not take any action against our physician. See the “Talking It Through” Box.

Another group of staff who can identify issues is billing and collections. Often a patient will experience a minor cumulative series of service breaches (eg, long wait, perceived physician distraction, long hold times on the phone) and then lose it when they receive a bill that is incorrect, late, or confusing. The staff members answering those calls also need to feel supported in asking for help from a manager or another associate, either during the call or by suggesting that someone call the patient back.

Empowering staff or managers with tangible service recovery courtesies is also a good idea. We gave our staff coupons from the sundries shop in the building, so that when experiencing a particularly long wait, the patient could go down and get a complimentary snack. We also had 1 or 2 occasions when a patient drove a great distance to see the physician and experienced a significant service breach. As part of our response, we gave the patient a gas card. 

Blue is the category in which the staff’s keen observation and true teamwork and support come into play when a situation or developing situation is identified.

Yellow

Yellow, while still contained within the practice, is overt. There has been an incident and/or a communication (letter or call) to the manager or physician. In Yellow, we are beyond the cooperative staff observation and sensory skills—we know something has happened. A situation might be physical- and/or facility-based, eg, a patient or family member had a minor stumble on a doormat, and though luckily they had not appeared injured and the physician checked them out, it was an incident. The other sign of a Yellow situation is that a patient or family member has written a letter to the practice to express their dissatisfaction. In either case, as dreadful as it may seem or as busy as you may be, follow up promptly.

In the case of an incident in the practice, the doctor or manager can call the patient that evening to check in and make sure all is well. Upon receiving a letter, the treating physician and manager should take a minute to discuss and agree on a response plan. Sometimes the situation may call for patient discharge from the practice—only the physician can determine that. Other times, the content of the letter may cause you to consult an attorney or your malpractice insurance carrier. The letters sometimes voice service-oriented complaints and can be addressed by the manager with a phone call and conversation as described in the Blue section above.  

Orange

As a consultant, I have assisted many physicians in responding to individual patient complaints to their state medical board (SMB). I have seen a 15-page, single-spaced, typewritten letter with photographs (of the patient’s 70-lb pannus, no less), a 4-sentence letter in childlike grammar and handwriting, and many in between. The spelling, grammar, punctuation, coherence, and brevity of the letter do not matter. Your feelings on the validity of the complaint (ie, “That’s total BS!”) don’t matter. The perceived mental health of the patient (ie,“Well, he’s crazy! Ask my nurse.”) does not matter. Your SMB takes each and every complaint letter very seriously and so must you. One complaint spiraling out of control can be all it takes for you to lose your license. Having said that, individual patient SMB complaints are not uncommon; even the best physicians receive them.

Here are some thoughts to keep in mind regarding individual patient SMB complaints. An individual patient SMB complaint:

◾ Typically comes to you via US mail with no receipt signature required. Lots of us do so much online these days we can go weeks, perhaps months, without looking at our mail—even if staff members have opened it.

Suggestion: Make sure the staff looks at mail and is able to judge what requires action and what should be brought to your attention. Provide appreciation and detailed feedback when staff members bring something to you and do not misdirect negative reactions regardless of the content. You would rather staff members feel comfortable bringing something to your attention that is immaterial than keep something important from you out of fear of displeasing you.

◾ Includes a SMB response deadline that may give you as little as 1 or 2 weeks.

Suggestion: Meet the deadline. If you have or are going to miss the deadline or know that you cannot meet it, have your staff call the SMB office and abjectly request an extension.

◾ Is coming from physicians as members of the SMB, even though it may have the names of physicians you know, perhaps friends, on the letterhead.

Suggestions:

1. The physicians are not your colleagues in this situation. In this capacity, each physician is a member of an oversight board that serves and protects the people of your state. Don’t try to address the situation with a phone call or comment on the golf course.

2. Reply in the format the board has requested—a letter. Open your response letter with a statement that acknowledges the work and responsibility of the SMB and your appreciation, for example:

Esteemed Board,

While I regret that a patient complaint associated with me has come to your attention, I am grateful that the physicians and the people of [your state] have an oversight body to ensure the integrity of medical care delivered and received. Thank you for your service.

◾ Is likely to make you feel angry, indignant, unappreciated, hurt, bewildered, etc.

Suggestion: Breathe, vent to someone you can trust, exercise, get a good night’s sleep, and/or other calming, self-preservation tactics. Repeat as necessary so as not to allow these emotions a place in your response.

◾ May or may not include a request for a copy of the complete medical record.

Suggestion: If the medical record is not requested, do not send it. If the medical record is requested, send it in its entirety, as is. Do not make changes, edits, or amendments to the medical record as a response to the complaint.

◾ May be brief, vague, long, articulate, well thought-out and well structured, and/or ridiculous. Regardless of education level, profession, age, and socioeconomic status, any of your patients may write a complaint letter to the SMB, who then must address it.

Suggestions:

1. Demonstrate respect for the board’s time and service by writing a response letter of respectable length and substance regardless of the brevity of the complaint. Brief responses to the SMB may be perceived as arrogant and irreverent, and this is the exact situation and group of people in the entire state in which and before whom you do not want to be thought of that way.

2. Summarize the case with detail and substance in the letter, even if the medical record will be included in the response. Identify the actual complaints and address them in an organized way, an objective voice, and a logical order. Describe the time, thought, and follow-up you have put into addressing the situation. For instance, if the complaint includes a legitimate reference to a delay in test results or an unreturned phone call, provide a broad description of having reviewed and modified the process with your staff to understand where the gap occurred and having taken measures to help keep it from happening again.

◾ Will likely require that a copy of your response be made available or sent to the complainant.

Suggestions:

1. You are writing to 2, maybe 3, recipients: the SMB, the complainant, and the complainant’s attorney. Even if it is clear the patient did not consult a lawyer to write the complaint, it is best to write the response as though it will be read by an attorney.

2. Take the time and deliberation necessary for a multiple-draft writing process. Get help from someone to assure you have addressed all the issues in an organized, objective way.

◾ May lead to a request from the SMB that you appear before them in response to the original complaint letter and/or to clarify your response to a complaint letter. This is an indication of an investigation that has escalated beyond the patient SMB complaint letters addressed in this article; consult an experienced attorney who represents you.

Sometimes other state oversight bodies will receive complaints directly from patients and follow up with you. Consult your attorney, risk management consultant, or malpractice coverage representative for guidance if you are unsure as to the jurisdiction or how to respond.

Conclusion

Most of your practice operates in the Green, no doubt. It is simply not noticeable or memorable when everything goes smoothly. When incidents occur that require service recovery, I hope this guide and commentary will offer perspective on the full range of patient relations and service recovery, provide stories and experiences that might help, and offer general tips and suggestions.

Tearful breakdowns and loud outbursts—they happen with orthopedic patients even in the best of practices. And if you are an orthopedic surgeon who has rarely or never experienced a patient in emotional distress, just talk with your staff—they have no doubt experienced this many times. 

There is something about orthopedic conditions—they carry with them an increased likelihood of emotional adverse effects for patients and their loved ones. Inhibited movement can lead to palpable frustration and depression. Time off from work may cause financial hardship and an identity crisis for a family breadwinner. Physical pain can cause the patient to become depressed, angry, or dependent on prescription medication. Medications can cause a change in disposition or outlook. These realities make orthopedic surgery practices particularly predisposed to patient relations risks and service recovery opportunities.

As a practice management consultant and former executive director of an orthopedic practice, I have observed and participated in patient relations and service recovery efforts at many levels. Particularly proud of the way our staff and physicians prevented and handled these and having spent many years traveling by air under the color-coded TSA (Transportation Security Administration) security level indicator system, I created the Patient Relations and Service Recovery Guide (Figure) to help practices gain perspective, have a vocabulary, and develop practical methods for mitigating patient relations risks and responding to incidents and complaints.

The Patient Relations and Service Recovery Guide

The Patient Relations and Service Recovery Guide shows the relationship between the practice as a whole and the patient as an individual. 

Green and Red

Green describes the elements of service orientation that the practice must consistently demonstrate and convey to each individual from the point of access, through treatment, and, finally, during account settlement. If you think you have a systemic problem with anything under the Green heading, you probably need a practice management or service orientation consultant, not this article. Red shows the other end of the spectrum—a complete degeneration, worst-case scenario.  As with problems in the Green category, this article will not help you in these Red situations, for which you need experienced legal counsel immediately.

We’ll now explore the stories, challenges, opportunities, and practical suggestions for the Blue, Yellow, and Orange categories. The Blue and Yellow categories in the Figure are shaded in grey as a depiction of the interactive, fluid nature of these situations. In addition, they are situations that have developed and can be resolved within and by the practice.

Blue

Patients are very comfortable complaining to the receptionist, x-ray technician, and medical assistant about any number of perceived shortcomings, but when you walk in the examination room, not a word. This is a reality I am sure you have heard about from your staff, and it puts them in a position to observe and determine if a patient’s frustration is escalating. Telephone and front desk receptions are first in line. Patients will say to a telephone receptionist, “I have called 3 times yesterday and twice today and the doctor/nurse still hasn’t called back.” Front desk receptionists will also observe dynamics in the seating area. Staff are your partners in patient relations and service recovery. Working together effectively will help you address issues in the Blue and Yellow areas.

Create an environment that prevents patient discontent and supports service orientation goals. A hospital-based practice that I once managed was a flagship for service excellence goals of a Fortune 150 corporation, had a large seating area, and was close to the airport in a city with multiple company properties; we frequently had executives showing up unannounced, and, because of company politics, it seemed like they were actively looking for instances of substandard service. More importantly, though, we had patients. We established “Waiting Stories” as a performance standard for the receptionists. That is, at any moment, the receptionist was able to recap the “story” of each person in the seating area. The “story” is the reason the person was there, the appointment time, and the cause of the delay, if the wait time was excessive. We all knew this was a performance standard for our practice, so if a receptionist called back to the clinic to find out the reason for a backup in throughput, everyone was respectful and responsive to the inquiry. 

The receptionists quickly became effective in judging situations and mitigating or avoiding breakdowns in service and communication. We also implemented an easy and quick notification code for when they needed help handling a service recovery situation. The responses and support in those situations were unwavering, consistent, and blame-free. We would debrief after a significant situation was resolved to determine if there were systemic or response improvement opportunities.

Communication among staff is essential for preventing or mitigating patient discontent. All practices experience service and throughput errors occasionally: a quiet, uncomplaining patient inadvertently doesn’t get called back and remains in the seating area unnoticed; a call doesn’t get returned; x-ray breaks down and a spine patient has to make a painful walk; the physician has to interrupt the encounter to take an important call; etc. Stuff happens. Individually, these breaches are tolerable to most patients. Unfortunately, there can be a cumulative element—when various service mishaps happen to the same patient. This is when communication and support among the staff and with the manager become especially important. If a patient has weathered a rough or long wait or has expressed some dissatisfaction while in the reception area, it’s probably a good idea to let the back-office staff know, so they can show a little extra compassion and be cognizant of additional situations.

Clinical staff and the physicians must convey support and appreciation to front-line staff who observe and share that a patient may be prone to distress, so that they will continue to participate in active incident prevention and service recovery. 

Heightening awareness on the part of your staff—especially, receptionists, technicians, medical assistants, and collectors—goes a long way toward getting patient discontent issues settled before they get out of hand. As executive director of a large orthopedic surgery practice, I was particularly proud of our staff’s sensitivity to patient discontent, their sense of when it might be helpful to bring in a manager, and the managers’ ability both to recover many situations and to know when it was most effective to get help and support from either one of the executive team or physicians.

I can remember one patient that both front-line staff and the manager determined needed some service recovery intervention. She had been visibly upset at the end of her final postoperative visit with the physician. The staff noticed and called the manager in. The patient mentioned to the manager that she had been to another orthopedic surgeon who had told her that the surgery our physician had performed was not the right one and that he would have done things differently. The patient said she just didn’t know what to do. Our manager had the keen sense to know that she should get help to recover the situation within our practice. She and all of the staff were always supported when they asked for help, and the physicians were good about expressing their gratitude to the staff for their efforts. The manager escorted the upset patient to my office where we talked—well, she mostly talked and I listened. It turned out that her injuries had prevented her from attending games during her only child’s senior soccer season. I know, it sounds more like therapy—it was a lot of listening and compassion on my part. Eventually, she got around to thanking me for listening. And while that was not the end of it (there was another conversation), she did not take any action against our physician. See the “Talking It Through” Box.

Another group of staff who can identify issues is billing and collections. Often a patient will experience a minor cumulative series of service breaches (eg, long wait, perceived physician distraction, long hold times on the phone) and then lose it when they receive a bill that is incorrect, late, or confusing. The staff members answering those calls also need to feel supported in asking for help from a manager or another associate, either during the call or by suggesting that someone call the patient back.

Empowering staff or managers with tangible service recovery courtesies is also a good idea. We gave our staff coupons from the sundries shop in the building, so that when experiencing a particularly long wait, the patient could go down and get a complimentary snack. We also had 1 or 2 occasions when a patient drove a great distance to see the physician and experienced a significant service breach. As part of our response, we gave the patient a gas card. 

Blue is the category in which the staff’s keen observation and true teamwork and support come into play when a situation or developing situation is identified.

Yellow

Yellow, while still contained within the practice, is overt. There has been an incident and/or a communication (letter or call) to the manager or physician. In Yellow, we are beyond the cooperative staff observation and sensory skills—we know something has happened. A situation might be physical- and/or facility-based, eg, a patient or family member had a minor stumble on a doormat, and though luckily they had not appeared injured and the physician checked them out, it was an incident. The other sign of a Yellow situation is that a patient or family member has written a letter to the practice to express their dissatisfaction. In either case, as dreadful as it may seem or as busy as you may be, follow up promptly.

In the case of an incident in the practice, the doctor or manager can call the patient that evening to check in and make sure all is well. Upon receiving a letter, the treating physician and manager should take a minute to discuss and agree on a response plan. Sometimes the situation may call for patient discharge from the practice—only the physician can determine that. Other times, the content of the letter may cause you to consult an attorney or your malpractice insurance carrier. The letters sometimes voice service-oriented complaints and can be addressed by the manager with a phone call and conversation as described in the Blue section above.  

Orange

As a consultant, I have assisted many physicians in responding to individual patient complaints to their state medical board (SMB). I have seen a 15-page, single-spaced, typewritten letter with photographs (of the patient’s 70-lb pannus, no less), a 4-sentence letter in childlike grammar and handwriting, and many in between. The spelling, grammar, punctuation, coherence, and brevity of the letter do not matter. Your feelings on the validity of the complaint (ie, “That’s total BS!”) don’t matter. The perceived mental health of the patient (ie,“Well, he’s crazy! Ask my nurse.”) does not matter. Your SMB takes each and every complaint letter very seriously and so must you. One complaint spiraling out of control can be all it takes for you to lose your license. Having said that, individual patient SMB complaints are not uncommon; even the best physicians receive them.

Here are some thoughts to keep in mind regarding individual patient SMB complaints. An individual patient SMB complaint:

◾ Typically comes to you via US mail with no receipt signature required. Lots of us do so much online these days we can go weeks, perhaps months, without looking at our mail—even if staff members have opened it.

Suggestion: Make sure the staff looks at mail and is able to judge what requires action and what should be brought to your attention. Provide appreciation and detailed feedback when staff members bring something to you and do not misdirect negative reactions regardless of the content. You would rather staff members feel comfortable bringing something to your attention that is immaterial than keep something important from you out of fear of displeasing you.

◾ Includes a SMB response deadline that may give you as little as 1 or 2 weeks.

Suggestion: Meet the deadline. If you have or are going to miss the deadline or know that you cannot meet it, have your staff call the SMB office and abjectly request an extension.

◾ Is coming from physicians as members of the SMB, even though it may have the names of physicians you know, perhaps friends, on the letterhead.

Suggestions:

1. The physicians are not your colleagues in this situation. In this capacity, each physician is a member of an oversight board that serves and protects the people of your state. Don’t try to address the situation with a phone call or comment on the golf course.

2. Reply in the format the board has requested—a letter. Open your response letter with a statement that acknowledges the work and responsibility of the SMB and your appreciation, for example:

Esteemed Board,

While I regret that a patient complaint associated with me has come to your attention, I am grateful that the physicians and the people of [your state] have an oversight body to ensure the integrity of medical care delivered and received. Thank you for your service.

◾ Is likely to make you feel angry, indignant, unappreciated, hurt, bewildered, etc.

Suggestion: Breathe, vent to someone you can trust, exercise, get a good night’s sleep, and/or other calming, self-preservation tactics. Repeat as necessary so as not to allow these emotions a place in your response.

◾ May or may not include a request for a copy of the complete medical record.

Suggestion: If the medical record is not requested, do not send it. If the medical record is requested, send it in its entirety, as is. Do not make changes, edits, or amendments to the medical record as a response to the complaint.

◾ May be brief, vague, long, articulate, well thought-out and well structured, and/or ridiculous. Regardless of education level, profession, age, and socioeconomic status, any of your patients may write a complaint letter to the SMB, who then must address it.

Suggestions:

1. Demonstrate respect for the board’s time and service by writing a response letter of respectable length and substance regardless of the brevity of the complaint. Brief responses to the SMB may be perceived as arrogant and irreverent, and this is the exact situation and group of people in the entire state in which and before whom you do not want to be thought of that way.

2. Summarize the case with detail and substance in the letter, even if the medical record will be included in the response. Identify the actual complaints and address them in an organized way, an objective voice, and a logical order. Describe the time, thought, and follow-up you have put into addressing the situation. For instance, if the complaint includes a legitimate reference to a delay in test results or an unreturned phone call, provide a broad description of having reviewed and modified the process with your staff to understand where the gap occurred and having taken measures to help keep it from happening again.

◾ Will likely require that a copy of your response be made available or sent to the complainant.

Suggestions:

1. You are writing to 2, maybe 3, recipients: the SMB, the complainant, and the complainant’s attorney. Even if it is clear the patient did not consult a lawyer to write the complaint, it is best to write the response as though it will be read by an attorney.

2. Take the time and deliberation necessary for a multiple-draft writing process. Get help from someone to assure you have addressed all the issues in an organized, objective way.

◾ May lead to a request from the SMB that you appear before them in response to the original complaint letter and/or to clarify your response to a complaint letter. This is an indication of an investigation that has escalated beyond the patient SMB complaint letters addressed in this article; consult an experienced attorney who represents you.

Sometimes other state oversight bodies will receive complaints directly from patients and follow up with you. Consult your attorney, risk management consultant, or malpractice coverage representative for guidance if you are unsure as to the jurisdiction or how to respond.

Conclusion

Most of your practice operates in the Green, no doubt. It is simply not noticeable or memorable when everything goes smoothly. When incidents occur that require service recovery, I hope this guide and commentary will offer perspective on the full range of patient relations and service recovery, provide stories and experiences that might help, and offer general tips and suggestions.

Tearful breakdowns and loud outbursts—they happen with orthopedic patients even in the best of practices. And if you are an orthopedic surgeon who has rarely or never experienced a patient in emotional distress, just talk with your staff—they have no doubt experienced this many times. 

There is something about orthopedic conditions—they carry with them an increased likelihood of emotional adverse effects for patients and their loved ones. Inhibited movement can lead to palpable frustration and depression. Time off from work may cause financial hardship and an identity crisis for a family breadwinner. Physical pain can cause the patient to become depressed, angry, or dependent on prescription medication. Medications can cause a change in disposition or outlook. These realities make orthopedic surgery practices particularly predisposed to patient relations risks and service recovery opportunities.

As a practice management consultant and former executive director of an orthopedic practice, I have observed and participated in patient relations and service recovery efforts at many levels. Particularly proud of the way our staff and physicians prevented and handled these and having spent many years traveling by air under the color-coded TSA (Transportation Security Administration) security level indicator system, I created the Patient Relations and Service Recovery Guide (Figure) to help practices gain perspective, have a vocabulary, and develop practical methods for mitigating patient relations risks and responding to incidents and complaints.

The Patient Relations and Service Recovery Guide

The Patient Relations and Service Recovery Guide shows the relationship between the practice as a whole and the patient as an individual. 

Green and Red

Green describes the elements of service orientation that the practice must consistently demonstrate and convey to each individual from the point of access, through treatment, and, finally, during account settlement. If you think you have a systemic problem with anything under the Green heading, you probably need a practice management or service orientation consultant, not this article. Red shows the other end of the spectrum—a complete degeneration, worst-case scenario.  As with problems in the Green category, this article will not help you in these Red situations, for which you need experienced legal counsel immediately.

We’ll now explore the stories, challenges, opportunities, and practical suggestions for the Blue, Yellow, and Orange categories. The Blue and Yellow categories in the Figure are shaded in grey as a depiction of the interactive, fluid nature of these situations. In addition, they are situations that have developed and can be resolved within and by the practice.

Blue

Patients are very comfortable complaining to the receptionist, x-ray technician, and medical assistant about any number of perceived shortcomings, but when you walk in the examination room, not a word. This is a reality I am sure you have heard about from your staff, and it puts them in a position to observe and determine if a patient’s frustration is escalating. Telephone and front desk receptions are first in line. Patients will say to a telephone receptionist, “I have called 3 times yesterday and twice today and the doctor/nurse still hasn’t called back.” Front desk receptionists will also observe dynamics in the seating area. Staff are your partners in patient relations and service recovery. Working together effectively will help you address issues in the Blue and Yellow areas.

Create an environment that prevents patient discontent and supports service orientation goals. A hospital-based practice that I once managed was a flagship for service excellence goals of a Fortune 150 corporation, had a large seating area, and was close to the airport in a city with multiple company properties; we frequently had executives showing up unannounced, and, because of company politics, it seemed like they were actively looking for instances of substandard service. More importantly, though, we had patients. We established “Waiting Stories” as a performance standard for the receptionists. That is, at any moment, the receptionist was able to recap the “story” of each person in the seating area. The “story” is the reason the person was there, the appointment time, and the cause of the delay, if the wait time was excessive. We all knew this was a performance standard for our practice, so if a receptionist called back to the clinic to find out the reason for a backup in throughput, everyone was respectful and responsive to the inquiry. 

The receptionists quickly became effective in judging situations and mitigating or avoiding breakdowns in service and communication. We also implemented an easy and quick notification code for when they needed help handling a service recovery situation. The responses and support in those situations were unwavering, consistent, and blame-free. We would debrief after a significant situation was resolved to determine if there were systemic or response improvement opportunities.

Communication among staff is essential for preventing or mitigating patient discontent. All practices experience service and throughput errors occasionally: a quiet, uncomplaining patient inadvertently doesn’t get called back and remains in the seating area unnoticed; a call doesn’t get returned; x-ray breaks down and a spine patient has to make a painful walk; the physician has to interrupt the encounter to take an important call; etc. Stuff happens. Individually, these breaches are tolerable to most patients. Unfortunately, there can be a cumulative element—when various service mishaps happen to the same patient. This is when communication and support among the staff and with the manager become especially important. If a patient has weathered a rough or long wait or has expressed some dissatisfaction while in the reception area, it’s probably a good idea to let the back-office staff know, so they can show a little extra compassion and be cognizant of additional situations.

Clinical staff and the physicians must convey support and appreciation to front-line staff who observe and share that a patient may be prone to distress, so that they will continue to participate in active incident prevention and service recovery. 

Heightening awareness on the part of your staff—especially, receptionists, technicians, medical assistants, and collectors—goes a long way toward getting patient discontent issues settled before they get out of hand. As executive director of a large orthopedic surgery practice, I was particularly proud of our staff’s sensitivity to patient discontent, their sense of when it might be helpful to bring in a manager, and the managers’ ability both to recover many situations and to know when it was most effective to get help and support from either one of the executive team or physicians.

I can remember one patient that both front-line staff and the manager determined needed some service recovery intervention. She had been visibly upset at the end of her final postoperative visit with the physician. The staff noticed and called the manager in. The patient mentioned to the manager that she had been to another orthopedic surgeon who had told her that the surgery our physician had performed was not the right one and that he would have done things differently. The patient said she just didn’t know what to do. Our manager had the keen sense to know that she should get help to recover the situation within our practice. She and all of the staff were always supported when they asked for help, and the physicians were good about expressing their gratitude to the staff for their efforts. The manager escorted the upset patient to my office where we talked—well, she mostly talked and I listened. It turned out that her injuries had prevented her from attending games during her only child’s senior soccer season. I know, it sounds more like therapy—it was a lot of listening and compassion on my part. Eventually, she got around to thanking me for listening. And while that was not the end of it (there was another conversation), she did not take any action against our physician. See the “Talking It Through” Box.

Another group of staff who can identify issues is billing and collections. Often a patient will experience a minor cumulative series of service breaches (eg, long wait, perceived physician distraction, long hold times on the phone) and then lose it when they receive a bill that is incorrect, late, or confusing. The staff members answering those calls also need to feel supported in asking for help from a manager or another associate, either during the call or by suggesting that someone call the patient back.

Empowering staff or managers with tangible service recovery courtesies is also a good idea. We gave our staff coupons from the sundries shop in the building, so that when experiencing a particularly long wait, the patient could go down and get a complimentary snack. We also had 1 or 2 occasions when a patient drove a great distance to see the physician and experienced a significant service breach. As part of our response, we gave the patient a gas card. 

Blue is the category in which the staff’s keen observation and true teamwork and support come into play when a situation or developing situation is identified.

Yellow

Yellow, while still contained within the practice, is overt. There has been an incident and/or a communication (letter or call) to the manager or physician. In Yellow, we are beyond the cooperative staff observation and sensory skills—we know something has happened. A situation might be physical- and/or facility-based, eg, a patient or family member had a minor stumble on a doormat, and though luckily they had not appeared injured and the physician checked them out, it was an incident. The other sign of a Yellow situation is that a patient or family member has written a letter to the practice to express their dissatisfaction. In either case, as dreadful as it may seem or as busy as you may be, follow up promptly.

In the case of an incident in the practice, the doctor or manager can call the patient that evening to check in and make sure all is well. Upon receiving a letter, the treating physician and manager should take a minute to discuss and agree on a response plan. Sometimes the situation may call for patient discharge from the practice—only the physician can determine that. Other times, the content of the letter may cause you to consult an attorney or your malpractice insurance carrier. The letters sometimes voice service-oriented complaints and can be addressed by the manager with a phone call and conversation as described in the Blue section above.  

Orange

As a consultant, I have assisted many physicians in responding to individual patient complaints to their state medical board (SMB). I have seen a 15-page, single-spaced, typewritten letter with photographs (of the patient’s 70-lb pannus, no less), a 4-sentence letter in childlike grammar and handwriting, and many in between. The spelling, grammar, punctuation, coherence, and brevity of the letter do not matter. Your feelings on the validity of the complaint (ie, “That’s total BS!”) don’t matter. The perceived mental health of the patient (ie,“Well, he’s crazy! Ask my nurse.”) does not matter. Your SMB takes each and every complaint letter very seriously and so must you. One complaint spiraling out of control can be all it takes for you to lose your license. Having said that, individual patient SMB complaints are not uncommon; even the best physicians receive them.

Here are some thoughts to keep in mind regarding individual patient SMB complaints. An individual patient SMB complaint:

◾ Typically comes to you via US mail with no receipt signature required. Lots of us do so much online these days we can go weeks, perhaps months, without looking at our mail—even if staff members have opened it.

Suggestion: Make sure the staff looks at mail and is able to judge what requires action and what should be brought to your attention. Provide appreciation and detailed feedback when staff members bring something to you and do not misdirect negative reactions regardless of the content. You would rather staff members feel comfortable bringing something to your attention that is immaterial than keep something important from you out of fear of displeasing you.

◾ Includes a SMB response deadline that may give you as little as 1 or 2 weeks.

Suggestion: Meet the deadline. If you have or are going to miss the deadline or know that you cannot meet it, have your staff call the SMB office and abjectly request an extension.

◾ Is coming from physicians as members of the SMB, even though it may have the names of physicians you know, perhaps friends, on the letterhead.

Suggestions:

1. The physicians are not your colleagues in this situation. In this capacity, each physician is a member of an oversight board that serves and protects the people of your state. Don’t try to address the situation with a phone call or comment on the golf course.

2. Reply in the format the board has requested—a letter. Open your response letter with a statement that acknowledges the work and responsibility of the SMB and your appreciation, for example:

Esteemed Board,

While I regret that a patient complaint associated with me has come to your attention, I am grateful that the physicians and the people of [your state] have an oversight body to ensure the integrity of medical care delivered and received. Thank you for your service.

◾ Is likely to make you feel angry, indignant, unappreciated, hurt, bewildered, etc.

Suggestion: Breathe, vent to someone you can trust, exercise, get a good night’s sleep, and/or other calming, self-preservation tactics. Repeat as necessary so as not to allow these emotions a place in your response.

◾ May or may not include a request for a copy of the complete medical record.

Suggestion: If the medical record is not requested, do not send it. If the medical record is requested, send it in its entirety, as is. Do not make changes, edits, or amendments to the medical record as a response to the complaint.

◾ May be brief, vague, long, articulate, well thought-out and well structured, and/or ridiculous. Regardless of education level, profession, age, and socioeconomic status, any of your patients may write a complaint letter to the SMB, who then must address it.

Suggestions:

1. Demonstrate respect for the board’s time and service by writing a response letter of respectable length and substance regardless of the brevity of the complaint. Brief responses to the SMB may be perceived as arrogant and irreverent, and this is the exact situation and group of people in the entire state in which and before whom you do not want to be thought of that way.

2. Summarize the case with detail and substance in the letter, even if the medical record will be included in the response. Identify the actual complaints and address them in an organized way, an objective voice, and a logical order. Describe the time, thought, and follow-up you have put into addressing the situation. For instance, if the complaint includes a legitimate reference to a delay in test results or an unreturned phone call, provide a broad description of having reviewed and modified the process with your staff to understand where the gap occurred and having taken measures to help keep it from happening again.

◾ Will likely require that a copy of your response be made available or sent to the complainant.

Suggestions:

1. You are writing to 2, maybe 3, recipients: the SMB, the complainant, and the complainant’s attorney. Even if it is clear the patient did not consult a lawyer to write the complaint, it is best to write the response as though it will be read by an attorney.

2. Take the time and deliberation necessary for a multiple-draft writing process. Get help from someone to assure you have addressed all the issues in an organized, objective way.

◾ May lead to a request from the SMB that you appear before them in response to the original complaint letter and/or to clarify your response to a complaint letter. This is an indication of an investigation that has escalated beyond the patient SMB complaint letters addressed in this article; consult an experienced attorney who represents you.

Sometimes other state oversight bodies will receive complaints directly from patients and follow up with you. Consult your attorney, risk management consultant, or malpractice coverage representative for guidance if you are unsure as to the jurisdiction or how to respond.

Conclusion

Most of your practice operates in the Green, no doubt. It is simply not noticeable or memorable when everything goes smoothly. When incidents occur that require service recovery, I hope this guide and commentary will offer perspective on the full range of patient relations and service recovery, provide stories and experiences that might help, and offer general tips and suggestions.

You currently offer a physical therapy (PT) service line but feel like it could be doing better, or you are thinking of adding PT services and are not sure where to begin. Either way, the thought of your patients and bottom line benefiting from PT services within your practice but without you having to manage another service line is appealing. Although related to orthopedic surgery and an obvious ancillary service, PT is a different type of practice that requires active management of the professionals, revenue cycle, operations, regulatory requirements, and changing coding and reimbursement protocols. There are more and more companies nationwide that claim a mastery of the PT management niche and would be more than happy to shoulder your burden and share in your profits. Whether you already have PT services in your practice or are looking to add them, proceed with care and caution as you consider partnering with a PT management company. 

Drawing on my involvement with both successful PT management–orthopedic practice partnerships and the arduous, expensive demise of one, this article offers my recommendations for determining if a PT management partnership is best for your practice. Many of the contracts last for several years and include clauses that are extremely binding even after the contract conclusion. As with any decision to outsource, the decision to outsource PT services deserves a comprehensive request for proposal (RFP) to multiple candidate companies, a thorough vetting and decision process that includes all partners or an executive committee/board, and legal review of the contract by an experienced health care attorney representing the practice.

Request for Proposal

Begin the RFP with a reference to your website and a brief description of the practice and current PT services. For example, state that you don’t have PT and are looking to start it, or, if your practice offers PT, include a description of the number of locations, square footage allocation, and number of full-time equivalent (FTE) physical therapists, occupational therapists, physical therapy assistants, and support staff of the existing program. Also mention whether the billing is done within the practice or is outsourced.

Next, you want to learn about the company. Ask about its number of years in PT management and the history of the company. Ask them to provide the previous business names and an overview of the history of ownership. You want to know this because the national PT management community is relatively small and includes frequent acquisitions and mergers. Just as important as the company’s history is any future plans it has to acquire or be acquired. This is all part of knowing who you may be partnering with.

You will want to know how many other practices the company provides PT/occupational therapy (OT) management services for, in what states those practices are located, and a breakdown of specialties. The number of physician providers the company represents along with the answers to the other questions will give you an idea of its size, experience, location, alignment, and focus. Some of these companies manage PT in family practices. You will want to know how many orthopedic practices the company partners with. If your practice has subspecialties, ask about its experience with subspecialty orthopedics.

Ask for the company’s website so that you can get an idea of the company and its mission, vision, and values. Even though you will likely be interacting with regional representatives, you will be signing the contract with the company leadership, so be sure to learn—either from the company’s website or its response to the RFP—about the individuals leading the organization and any parent company. Ask for a list of officers, board of directors, managers, and perhaps an organization chart with titles and names. Because you are looking to partner with the company, it might be good to ask for managerial turnover rates in the last few years. PT is a professional health care service, so take note of the number of licensed therapists the company has in leadership positions. If you were partnering with a medical organization, you would certainly want physicians in leadership positions, and this is no different. Determine if the company is publicly traded or privately held. You may also consider requesting the company’s last few annual reports to learn more.

Exclusivity

Some PT management companies have their own facilities and are partnering with practices in the same market despite the seemingly inherent conflict. As part of your RFP, ask the company to include the names of practices, their specialties, and site locations where it already has a presence as well as a list of its own (independent of a physician practice) locations in the state or region. Future plans are important here too; if the company does not currently have a presence in the region, what commitment will it make to exclusivity or noncompete?

Human Resources

In many cases, the PT management company actually employs the entire staff for the service line. If you already have PT in your practice, this means the employees will transition from your employment to another company. After the contract is signed, some of the employees will get paychecks and benefits from your practice and be subject to your practice’s policies, while others will not. Having 2 different employers in the same practice can have an impact on employee morale and satisfaction. Find out during the proposal process if the company’s typical model is based on the company’s or the practice’s employment of the professional and support staff.             

Obtain the following information from the management company if it is to be the employer:

1.  Titles and compensation ranges for each position

2.  Description of all bonuses and incentive structures

3.  Paid time off (PTO) policies and accrual rates

4.  Paid holidays

5.  Details of employee benefits, such as employee out-of-pocket premiums for individual and family health care coverage, availability of vision and dental coverage, and investment and match for retirement or 401(k) plans.

6.  Human resources (HR) support. Describe how employees get needed support from human resources, such as questions about benefits, FMLA (Family Medical Leave Act), HR policies, and other issues.

7.  Results of any employee satisfaction surveys completed in the last 2 years

8.  Nonrecruitment. In what ways will the professional staff’s careers be affected by this partnership? Will the professional staff have to sign employment agreements? If so, please provide a sample. Will there be covenants not to compete for the professional staff?

9.  Provide a schematic on how you typically cover professional staff vacation and family leave.

10. Does your organization provide accredited continuing education for professional staff or do you send staff to state and national meetings and courses to maintain their CEU (continuing education units) requirement?

11. Do you provide annual regulatory training, such as HIPAA (Health Insurance Portability and Accountability Act) training, for all staff or is the practice responsible for that?

12. Professional liability coverage for the therapists.

Initially, the company may say they are open to doing it either way and you may proceed with the process without answers to these questions. If at any point, you explore a situation in which the employer is not the practice, you must get answers to these questions before agreeing to anything. Number 8 above is extremely important. Many PT management companies will include a nonrecruitment clause in their contracts so that neither party can recruit therapists from the engagement. Depending on how the clause is written, you may not be able to legally hire therapists who were with you for years before the management agreement at the conclusion of the contract. Individual therapists can find themselves very limited in where they can work in the community depending on a covenant not to compete. And while covenants not to compete and nonrecruitment clauses may be generalized as “indefensible,” it is expensive, time-consuming, and exhausting to get one rendered as such after the fact.

Operations

Operational compatibility is essential to a smooth transition or start-up. As part of your RFP, let the candidate companies know which electronic medical record (EMR) and electronic practice management (EPM) systems you use and ask about their experience level with those. Ask if it is expected that PT will operate on the practice’s EMR and EPM systems or if the company will be having PT operate on separate systems. If the company will be implementing different systems, find out which one and then do an accounting of the costs for interface, training, and other compatibility elements.

Inquire as to each candidate company’s standard operations policies and procedures as well as the operational and productivity standards the company maintains. For example, ask for a range of how many patients a physical therapist should be able to see (including documentation) in an 8-hour day? If you already have a PT service line, compare the company’s productivity standards to what your therapists are currently doing. Of the many enhancements a therapy management company can bring, an increase in productivity is essential. Request a description of productivity incentive programs for the professional staff so that you can determine if you are comfortable with them. By the same token, ask if the company has a comprehensive compliance program including procedures and policies.

Any outsourcing agreements will be subject to operational and contractual compliance elements such as HIPAA, business associates agreement, and all other applicable regulations through state, federal, and payor entities. Ask each candidate company about its compliance program.

Revenue Cycle

Some therapy management companies will leave the billing and collections to the practice, while others have their own operations. As part of the RFP, ask the company which way it is done in its standard model. If the company manages the revenue cycle, ask which key revenue cycle performance indicators it monitors, how it calculates them, and with what frequency it tracks and reports them. Ask how the company has approached a revenue cycle performance improvement effort and what successes it has had. And definitely ask about the emphasis, training, and performance standards on point-of-service (POS) collections. In PT, successful, service-oriented POS collections are essential to cash flow and patient satisfaction. Typically, there is a copayment for each visit, and patients come 3 times or more per week. When patients pay the copayment before each visit, it feels manageable to them. If they get a bill for 6 copayments 2 weeks into PT, they often get angry and do not see the value of the therapy. 

Seek specifics on the elements of the company’s performance improvement. A number of companies will default to providing incentive bonuses for POS collections and other revenue cycle improvements. Incentive bonuses for collections can compromise the coding and billing integrity of the practice and are guaranteed to cause discontent among support staff. Everyone who works hard should be recognized, not just the staff in a position to collect money. On top of this, if the PT reception staff are getting paid POS collections bonuses and the practice reception staff are not, a managerial dichotomy ensues.

Accounting and Financial Reporting

In your RFP, ask about the accounting and financial model that each candidate company most often uses. Inquire as to which—the practice or the management company—is responsible for monthly, quarterly, and annual accounting and financial reporting and what typical monthly reconcilement process the company recommends. Include the following requests in your RFP:

1.  Please provide samples of the monthly financials produced or preferred.

2.  Describe your annual expense and revenue budgeting and approval processes.

3.  Please address how you recommend handling the purchase of new equipment and supplies as well as the handling of existing equipment and supplies. 

4.  Will you rent our current space? Will you look to move the PT department into an alternate space in the future? If so, where?

General

Make some general inquiries that will help you get to know each organization and determine which one may be the best fit for a long, committed relationship with your practice. Find out how often the organization will have corporate representatives in the practice and at physician board meetings. Inquire as to the types of referral reports they generate and share with the practice. Request the names and contact information of 3 to 5 orthopedic surgery practice managers or physician leaders whom you can contact as references for the company. 

If you have an existing PT service line, ask the company how it proposes to enhance the services, quality, and bottom line. What value will the company’s management services add to an existing program?

Get to know the organization by asking how many of its partnering practices have terminated their agreements with the management company and if it has any current or past litigation with partner practices. These are detailed, binding contracts with the potential for a lot of money. When the relationships or even the local markets change, suits are filed.

As part of the RFP, inquire as to the standard proposed model for income distribution between the practice and the management company.

Conclusion

If your RFP covers all of the inquiries discussed in this article, it will be necessarily comprehensive. Send it to several companies with a clear indication of the response deadline and the contact person for the response and for any questions they may have. The contact person is typically the practice manager or executive administrator. Individual physicians in your group may have relationships with local representatives of a PT management company, and it can put them in an awkward position during the proposal submission and evaluation process.

Some companies may not respond to an RFP this comprehensive, which provides an unequivocal answer that they are not qualified to be your practice’s partner. Compare the responses you receive and set up presentations or conference calls for those companies whose proposals warrant it.

Hire your own health care attorney to review any and all contracts before signing. The HR support, exclusivity, income distribution models, compliance, and duration of these contracts must be approved by an experienced attorney that advocates for the practice alone.

You currently offer a physical therapy (PT) service line but feel like it could be doing better, or you are thinking of adding PT services and are not sure where to begin. Either way, the thought of your patients and bottom line benefiting from PT services within your practice but without you having to manage another service line is appealing. Although related to orthopedic surgery and an obvious ancillary service, PT is a different type of practice that requires active management of the professionals, revenue cycle, operations, regulatory requirements, and changing coding and reimbursement protocols. There are more and more companies nationwide that claim a mastery of the PT management niche and would be more than happy to shoulder your burden and share in your profits. Whether you already have PT services in your practice or are looking to add them, proceed with care and caution as you consider partnering with a PT management company. 

Drawing on my involvement with both successful PT management–orthopedic practice partnerships and the arduous, expensive demise of one, this article offers my recommendations for determining if a PT management partnership is best for your practice. Many of the contracts last for several years and include clauses that are extremely binding even after the contract conclusion. As with any decision to outsource, the decision to outsource PT services deserves a comprehensive request for proposal (RFP) to multiple candidate companies, a thorough vetting and decision process that includes all partners or an executive committee/board, and legal review of the contract by an experienced health care attorney representing the practice.

Request for Proposal

Begin the RFP with a reference to your website and a brief description of the practice and current PT services. For example, state that you don’t have PT and are looking to start it, or, if your practice offers PT, include a description of the number of locations, square footage allocation, and number of full-time equivalent (FTE) physical therapists, occupational therapists, physical therapy assistants, and support staff of the existing program. Also mention whether the billing is done within the practice or is outsourced.

Next, you want to learn about the company. Ask about its number of years in PT management and the history of the company. Ask them to provide the previous business names and an overview of the history of ownership. You want to know this because the national PT management community is relatively small and includes frequent acquisitions and mergers. Just as important as the company’s history is any future plans it has to acquire or be acquired. This is all part of knowing who you may be partnering with.

You will want to know how many other practices the company provides PT/occupational therapy (OT) management services for, in what states those practices are located, and a breakdown of specialties. The number of physician providers the company represents along with the answers to the other questions will give you an idea of its size, experience, location, alignment, and focus. Some of these companies manage PT in family practices. You will want to know how many orthopedic practices the company partners with. If your practice has subspecialties, ask about its experience with subspecialty orthopedics.

Ask for the company’s website so that you can get an idea of the company and its mission, vision, and values. Even though you will likely be interacting with regional representatives, you will be signing the contract with the company leadership, so be sure to learn—either from the company’s website or its response to the RFP—about the individuals leading the organization and any parent company. Ask for a list of officers, board of directors, managers, and perhaps an organization chart with titles and names. Because you are looking to partner with the company, it might be good to ask for managerial turnover rates in the last few years. PT is a professional health care service, so take note of the number of licensed therapists the company has in leadership positions. If you were partnering with a medical organization, you would certainly want physicians in leadership positions, and this is no different. Determine if the company is publicly traded or privately held. You may also consider requesting the company’s last few annual reports to learn more.

Exclusivity

Some PT management companies have their own facilities and are partnering with practices in the same market despite the seemingly inherent conflict. As part of your RFP, ask the company to include the names of practices, their specialties, and site locations where it already has a presence as well as a list of its own (independent of a physician practice) locations in the state or region. Future plans are important here too; if the company does not currently have a presence in the region, what commitment will it make to exclusivity or noncompete?

Human Resources

In many cases, the PT management company actually employs the entire staff for the service line. If you already have PT in your practice, this means the employees will transition from your employment to another company. After the contract is signed, some of the employees will get paychecks and benefits from your practice and be subject to your practice’s policies, while others will not. Having 2 different employers in the same practice can have an impact on employee morale and satisfaction. Find out during the proposal process if the company’s typical model is based on the company’s or the practice’s employment of the professional and support staff.             

Obtain the following information from the management company if it is to be the employer:

1.  Titles and compensation ranges for each position

2.  Description of all bonuses and incentive structures

3.  Paid time off (PTO) policies and accrual rates

4.  Paid holidays

5.  Details of employee benefits, such as employee out-of-pocket premiums for individual and family health care coverage, availability of vision and dental coverage, and investment and match for retirement or 401(k) plans.

6.  Human resources (HR) support. Describe how employees get needed support from human resources, such as questions about benefits, FMLA (Family Medical Leave Act), HR policies, and other issues.

7.  Results of any employee satisfaction surveys completed in the last 2 years

8.  Nonrecruitment. In what ways will the professional staff’s careers be affected by this partnership? Will the professional staff have to sign employment agreements? If so, please provide a sample. Will there be covenants not to compete for the professional staff?

9.  Provide a schematic on how you typically cover professional staff vacation and family leave.

10. Does your organization provide accredited continuing education for professional staff or do you send staff to state and national meetings and courses to maintain their CEU (continuing education units) requirement?

11. Do you provide annual regulatory training, such as HIPAA (Health Insurance Portability and Accountability Act) training, for all staff or is the practice responsible for that?

12. Professional liability coverage for the therapists.

Initially, the company may say they are open to doing it either way and you may proceed with the process without answers to these questions. If at any point, you explore a situation in which the employer is not the practice, you must get answers to these questions before agreeing to anything. Number 8 above is extremely important. Many PT management companies will include a nonrecruitment clause in their contracts so that neither party can recruit therapists from the engagement. Depending on how the clause is written, you may not be able to legally hire therapists who were with you for years before the management agreement at the conclusion of the contract. Individual therapists can find themselves very limited in where they can work in the community depending on a covenant not to compete. And while covenants not to compete and nonrecruitment clauses may be generalized as “indefensible,” it is expensive, time-consuming, and exhausting to get one rendered as such after the fact.

Operations

Operational compatibility is essential to a smooth transition or start-up. As part of your RFP, let the candidate companies know which electronic medical record (EMR) and electronic practice management (EPM) systems you use and ask about their experience level with those. Ask if it is expected that PT will operate on the practice’s EMR and EPM systems or if the company will be having PT operate on separate systems. If the company will be implementing different systems, find out which one and then do an accounting of the costs for interface, training, and other compatibility elements.

Inquire as to each candidate company’s standard operations policies and procedures as well as the operational and productivity standards the company maintains. For example, ask for a range of how many patients a physical therapist should be able to see (including documentation) in an 8-hour day? If you already have a PT service line, compare the company’s productivity standards to what your therapists are currently doing. Of the many enhancements a therapy management company can bring, an increase in productivity is essential. Request a description of productivity incentive programs for the professional staff so that you can determine if you are comfortable with them. By the same token, ask if the company has a comprehensive compliance program including procedures and policies.

Any outsourcing agreements will be subject to operational and contractual compliance elements such as HIPAA, business associates agreement, and all other applicable regulations through state, federal, and payor entities. Ask each candidate company about its compliance program.

Revenue Cycle

Some therapy management companies will leave the billing and collections to the practice, while others have their own operations. As part of the RFP, ask the company which way it is done in its standard model. If the company manages the revenue cycle, ask which key revenue cycle performance indicators it monitors, how it calculates them, and with what frequency it tracks and reports them. Ask how the company has approached a revenue cycle performance improvement effort and what successes it has had. And definitely ask about the emphasis, training, and performance standards on point-of-service (POS) collections. In PT, successful, service-oriented POS collections are essential to cash flow and patient satisfaction. Typically, there is a copayment for each visit, and patients come 3 times or more per week. When patients pay the copayment before each visit, it feels manageable to them. If they get a bill for 6 copayments 2 weeks into PT, they often get angry and do not see the value of the therapy. 

Seek specifics on the elements of the company’s performance improvement. A number of companies will default to providing incentive bonuses for POS collections and other revenue cycle improvements. Incentive bonuses for collections can compromise the coding and billing integrity of the practice and are guaranteed to cause discontent among support staff. Everyone who works hard should be recognized, not just the staff in a position to collect money. On top of this, if the PT reception staff are getting paid POS collections bonuses and the practice reception staff are not, a managerial dichotomy ensues.

Accounting and Financial Reporting

In your RFP, ask about the accounting and financial model that each candidate company most often uses. Inquire as to which—the practice or the management company—is responsible for monthly, quarterly, and annual accounting and financial reporting and what typical monthly reconcilement process the company recommends. Include the following requests in your RFP:

1.  Please provide samples of the monthly financials produced or preferred.

2.  Describe your annual expense and revenue budgeting and approval processes.

3.  Please address how you recommend handling the purchase of new equipment and supplies as well as the handling of existing equipment and supplies. 

4.  Will you rent our current space? Will you look to move the PT department into an alternate space in the future? If so, where?

General

Make some general inquiries that will help you get to know each organization and determine which one may be the best fit for a long, committed relationship with your practice. Find out how often the organization will have corporate representatives in the practice and at physician board meetings. Inquire as to the types of referral reports they generate and share with the practice. Request the names and contact information of 3 to 5 orthopedic surgery practice managers or physician leaders whom you can contact as references for the company. 

If you have an existing PT service line, ask the company how it proposes to enhance the services, quality, and bottom line. What value will the company’s management services add to an existing program?

Get to know the organization by asking how many of its partnering practices have terminated their agreements with the management company and if it has any current or past litigation with partner practices. These are detailed, binding contracts with the potential for a lot of money. When the relationships or even the local markets change, suits are filed.

As part of the RFP, inquire as to the standard proposed model for income distribution between the practice and the management company.

Conclusion

If your RFP covers all of the inquiries discussed in this article, it will be necessarily comprehensive. Send it to several companies with a clear indication of the response deadline and the contact person for the response and for any questions they may have. The contact person is typically the practice manager or executive administrator. Individual physicians in your group may have relationships with local representatives of a PT management company, and it can put them in an awkward position during the proposal submission and evaluation process.

Some companies may not respond to an RFP this comprehensive, which provides an unequivocal answer that they are not qualified to be your practice’s partner. Compare the responses you receive and set up presentations or conference calls for those companies whose proposals warrant it.

Hire your own health care attorney to review any and all contracts before signing. The HR support, exclusivity, income distribution models, compliance, and duration of these contracts must be approved by an experienced attorney that advocates for the practice alone.

You currently offer a physical therapy (PT) service line but feel like it could be doing better, or you are thinking of adding PT services and are not sure where to begin. Either way, the thought of your patients and bottom line benefiting from PT services within your practice but without you having to manage another service line is appealing. Although related to orthopedic surgery and an obvious ancillary service, PT is a different type of practice that requires active management of the professionals, revenue cycle, operations, regulatory requirements, and changing coding and reimbursement protocols. There are more and more companies nationwide that claim a mastery of the PT management niche and would be more than happy to shoulder your burden and share in your profits. Whether you already have PT services in your practice or are looking to add them, proceed with care and caution as you consider partnering with a PT management company. 

Drawing on my involvement with both successful PT management–orthopedic practice partnerships and the arduous, expensive demise of one, this article offers my recommendations for determining if a PT management partnership is best for your practice. Many of the contracts last for several years and include clauses that are extremely binding even after the contract conclusion. As with any decision to outsource, the decision to outsource PT services deserves a comprehensive request for proposal (RFP) to multiple candidate companies, a thorough vetting and decision process that includes all partners or an executive committee/board, and legal review of the contract by an experienced health care attorney representing the practice.

Request for Proposal

Begin the RFP with a reference to your website and a brief description of the practice and current PT services. For example, state that you don’t have PT and are looking to start it, or, if your practice offers PT, include a description of the number of locations, square footage allocation, and number of full-time equivalent (FTE) physical therapists, occupational therapists, physical therapy assistants, and support staff of the existing program. Also mention whether the billing is done within the practice or is outsourced.

Next, you want to learn about the company. Ask about its number of years in PT management and the history of the company. Ask them to provide the previous business names and an overview of the history of ownership. You want to know this because the national PT management community is relatively small and includes frequent acquisitions and mergers. Just as important as the company’s history is any future plans it has to acquire or be acquired. This is all part of knowing who you may be partnering with.

You will want to know how many other practices the company provides PT/occupational therapy (OT) management services for, in what states those practices are located, and a breakdown of specialties. The number of physician providers the company represents along with the answers to the other questions will give you an idea of its size, experience, location, alignment, and focus. Some of these companies manage PT in family practices. You will want to know how many orthopedic practices the company partners with. If your practice has subspecialties, ask about its experience with subspecialty orthopedics.

Ask for the company’s website so that you can get an idea of the company and its mission, vision, and values. Even though you will likely be interacting with regional representatives, you will be signing the contract with the company leadership, so be sure to learn—either from the company’s website or its response to the RFP—about the individuals leading the organization and any parent company. Ask for a list of officers, board of directors, managers, and perhaps an organization chart with titles and names. Because you are looking to partner with the company, it might be good to ask for managerial turnover rates in the last few years. PT is a professional health care service, so take note of the number of licensed therapists the company has in leadership positions. If you were partnering with a medical organization, you would certainly want physicians in leadership positions, and this is no different. Determine if the company is publicly traded or privately held. You may also consider requesting the company’s last few annual reports to learn more.

Exclusivity

Some PT management companies have their own facilities and are partnering with practices in the same market despite the seemingly inherent conflict. As part of your RFP, ask the company to include the names of practices, their specialties, and site locations where it already has a presence as well as a list of its own (independent of a physician practice) locations in the state or region. Future plans are important here too; if the company does not currently have a presence in the region, what commitment will it make to exclusivity or noncompete?

Human Resources

In many cases, the PT management company actually employs the entire staff for the service line. If you already have PT in your practice, this means the employees will transition from your employment to another company. After the contract is signed, some of the employees will get paychecks and benefits from your practice and be subject to your practice’s policies, while others will not. Having 2 different employers in the same practice can have an impact on employee morale and satisfaction. Find out during the proposal process if the company’s typical model is based on the company’s or the practice’s employment of the professional and support staff.             

Obtain the following information from the management company if it is to be the employer:

1.  Titles and compensation ranges for each position

2.  Description of all bonuses and incentive structures

3.  Paid time off (PTO) policies and accrual rates

4.  Paid holidays

5.  Details of employee benefits, such as employee out-of-pocket premiums for individual and family health care coverage, availability of vision and dental coverage, and investment and match for retirement or 401(k) plans.

6.  Human resources (HR) support. Describe how employees get needed support from human resources, such as questions about benefits, FMLA (Family Medical Leave Act), HR policies, and other issues.

7.  Results of any employee satisfaction surveys completed in the last 2 years

8.  Nonrecruitment. In what ways will the professional staff’s careers be affected by this partnership? Will the professional staff have to sign employment agreements? If so, please provide a sample. Will there be covenants not to compete for the professional staff?

9.  Provide a schematic on how you typically cover professional staff vacation and family leave.

10. Does your organization provide accredited continuing education for professional staff or do you send staff to state and national meetings and courses to maintain their CEU (continuing education units) requirement?

11. Do you provide annual regulatory training, such as HIPAA (Health Insurance Portability and Accountability Act) training, for all staff or is the practice responsible for that?

12. Professional liability coverage for the therapists.

Initially, the company may say they are open to doing it either way and you may proceed with the process without answers to these questions. If at any point, you explore a situation in which the employer is not the practice, you must get answers to these questions before agreeing to anything. Number 8 above is extremely important. Many PT management companies will include a nonrecruitment clause in their contracts so that neither party can recruit therapists from the engagement. Depending on how the clause is written, you may not be able to legally hire therapists who were with you for years before the management agreement at the conclusion of the contract. Individual therapists can find themselves very limited in where they can work in the community depending on a covenant not to compete. And while covenants not to compete and nonrecruitment clauses may be generalized as “indefensible,” it is expensive, time-consuming, and exhausting to get one rendered as such after the fact.

Operations

Operational compatibility is essential to a smooth transition or start-up. As part of your RFP, let the candidate companies know which electronic medical record (EMR) and electronic practice management (EPM) systems you use and ask about their experience level with those. Ask if it is expected that PT will operate on the practice’s EMR and EPM systems or if the company will be having PT operate on separate systems. If the company will be implementing different systems, find out which one and then do an accounting of the costs for interface, training, and other compatibility elements.

Inquire as to each candidate company’s standard operations policies and procedures as well as the operational and productivity standards the company maintains. For example, ask for a range of how many patients a physical therapist should be able to see (including documentation) in an 8-hour day? If you already have a PT service line, compare the company’s productivity standards to what your therapists are currently doing. Of the many enhancements a therapy management company can bring, an increase in productivity is essential. Request a description of productivity incentive programs for the professional staff so that you can determine if you are comfortable with them. By the same token, ask if the company has a comprehensive compliance program including procedures and policies.

Any outsourcing agreements will be subject to operational and contractual compliance elements such as HIPAA, business associates agreement, and all other applicable regulations through state, federal, and payor entities. Ask each candidate company about its compliance program.

Revenue Cycle

Some therapy management companies will leave the billing and collections to the practice, while others have their own operations. As part of the RFP, ask the company which way it is done in its standard model. If the company manages the revenue cycle, ask which key revenue cycle performance indicators it monitors, how it calculates them, and with what frequency it tracks and reports them. Ask how the company has approached a revenue cycle performance improvement effort and what successes it has had. And definitely ask about the emphasis, training, and performance standards on point-of-service (POS) collections. In PT, successful, service-oriented POS collections are essential to cash flow and patient satisfaction. Typically, there is a copayment for each visit, and patients come 3 times or more per week. When patients pay the copayment before each visit, it feels manageable to them. If they get a bill for 6 copayments 2 weeks into PT, they often get angry and do not see the value of the therapy. 

Seek specifics on the elements of the company’s performance improvement. A number of companies will default to providing incentive bonuses for POS collections and other revenue cycle improvements. Incentive bonuses for collections can compromise the coding and billing integrity of the practice and are guaranteed to cause discontent among support staff. Everyone who works hard should be recognized, not just the staff in a position to collect money. On top of this, if the PT reception staff are getting paid POS collections bonuses and the practice reception staff are not, a managerial dichotomy ensues.

Accounting and Financial Reporting

In your RFP, ask about the accounting and financial model that each candidate company most often uses. Inquire as to which—the practice or the management company—is responsible for monthly, quarterly, and annual accounting and financial reporting and what typical monthly reconcilement process the company recommends. Include the following requests in your RFP:

1.  Please provide samples of the monthly financials produced or preferred.

2.  Describe your annual expense and revenue budgeting and approval processes.

3.  Please address how you recommend handling the purchase of new equipment and supplies as well as the handling of existing equipment and supplies. 

4.  Will you rent our current space? Will you look to move the PT department into an alternate space in the future? If so, where?

General

Make some general inquiries that will help you get to know each organization and determine which one may be the best fit for a long, committed relationship with your practice. Find out how often the organization will have corporate representatives in the practice and at physician board meetings. Inquire as to the types of referral reports they generate and share with the practice. Request the names and contact information of 3 to 5 orthopedic surgery practice managers or physician leaders whom you can contact as references for the company. 

If you have an existing PT service line, ask the company how it proposes to enhance the services, quality, and bottom line. What value will the company’s management services add to an existing program?

Get to know the organization by asking how many of its partnering practices have terminated their agreements with the management company and if it has any current or past litigation with partner practices. These are detailed, binding contracts with the potential for a lot of money. When the relationships or even the local markets change, suits are filed.

As part of the RFP, inquire as to the standard proposed model for income distribution between the practice and the management company.

Conclusion

If your RFP covers all of the inquiries discussed in this article, it will be necessarily comprehensive. Send it to several companies with a clear indication of the response deadline and the contact person for the response and for any questions they may have. The contact person is typically the practice manager or executive administrator. Individual physicians in your group may have relationships with local representatives of a PT management company, and it can put them in an awkward position during the proposal submission and evaluation process.

Some companies may not respond to an RFP this comprehensive, which provides an unequivocal answer that they are not qualified to be your practice’s partner. Compare the responses you receive and set up presentations or conference calls for those companies whose proposals warrant it.

Hire your own health care attorney to review any and all contracts before signing. The HR support, exclusivity, income distribution models, compliance, and duration of these contracts must be approved by an experienced attorney that advocates for the practice alone.