The Occupational Therapy Manager 6th EDITION Lead Editors: Karen Jacobs, EdD, OT, OTR, CPE, FAOTA, and Guy L. McCormack, PhD, OTR/L, FAOTA Associate Editors: Judith A. Parker Kent, OTD, EdS, OTR/L, FAOTA; Albert E. Copolillo, PhD, OTR/L, FAOTA; Roger I. Ideishi, JD, OT/L, FAOTA; Shawn Phipps, PhD, OTR/L, FAOTA; Sarah McKinnon, OT, OTR, OTD, BCPR, MPA; Donna Costa, DHS, OTR/L, FAOTA; Nathan B. Herz, OTD, MBA, OTR/L; Lea Brandt, OTD, MA, OTR/L; and Karen Duddy, OTD, MHA, OTR/L Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] AOTA Vision 2025 Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living. Mission Statement The American Occupational Therapy Association advances occupational therapy practice, education, and research through standard-setting and advocacy on behalf of its members, the profession, and the public. AOTA Staff Sherry Keramidas, Executive Director Christopher M. Bluhm, Chief Operating Officer Chris Davis, Associate Chief Officer for AOTA Press and Content Strategy Caroline Polk, Digital Manager and AJOT Managing Editor Ashley Hofmann, Development/Acquisitions Editor Barbara Dickson, Production Editor Rebecca Rutberg, Director, Marketing Amanda Goldman, Marketing Manager Jennifer Folden, Marketing Specialist American Occupational Therapy Association, Inc. 4720 Montgomery Lane Bethesda, MD 20814 Phone: 301-652-AOTA (2682) Fax: 301-652-7711 www.aota.org To order: 1-877-404-AOTA or store.aota.org © 2019 by the American Occupational Therapy Association, Inc. All rights reserved. No part of this book may be reproduced in whole or in part by any means without permission. Printed in the United States of America. Disclaimers This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold or distributed with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the services of a competent professional person should be sought. —From the Declaration of Principles jointly adopted by the American Bar Association and a Committee of Publishers and Associations It is the objective of the American Occupational Therapy Association to be a forum for free expression and interchange of ideas. The opinions expressed by the contributors to this work are their own and not necessarily those of the American Occupational Therapy Association. ISBN: 978-1-56900-390-9 Ebook ISBN: 978-1-56900-592-7 Library of Congress Control Number: 2019937715 Cover design by Debra Naylor, Naylor Design, Inc., Washington, DC Composition by Maryland Composition, White Plains, MD Printed by Automated Graphics, White Plains, MD Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Dedication To all current and future occupational therapy practitioners: May you be agents of change. —K. J. To the students, practitioners, managers, and leaders in occupational therapy. —G. M. iii Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Contents About the Editorsix About the Associate Editors and Contributorsxi List of Figures, Tables, Exhibits, Case Examples, and Appendixes xvii Note From the Publisher xxi Christina A. Davis Introductionxxiii Karen Jacobs, EdD, OT, OTR, CPE, FAOTA; Guy L. McCormack, PhD, OTR/L, FAOTA; Judith A. Parker Kent, OTD, EdS, OTR/L, FAOTA; Albert E. Copolillo, PhD, OTR/L, FAOTA; Roger I. Ideishi, JD, OT/L, FAOTA; Shawn Phipps, PhD, OTR/L, FAOTA; Sarah McKinnon, OT, OTR, OTD, BCPR, MPA; Donna Costa, DHS, OTR/L, FAOTA; Nathan B. Herz, OTD, MBA, OTR/L; Lea Brandt, OTD, MA, OTR/L; and Karen Duddy, OTD, MHA, OTR/L Section I. F oundations of Occupational Therapy Leadership and Management1 Edited by Karen Jacobs, EdD, OT, OTR, CPE, FAOTA Chapter 1. Theories of Leadership 3 Virginia “Ginny” Stoffel, PhD, OT, FAOTA Chapter 2. Perspectives on Management 19 Chapter 6. Leading and Managing Within Health Care Systems Chapter 7. Creating a Business in an Emerging Practice Area Chapter 8. Management for Occupation-Centered Practice Section II. Organizational Planning and Culture Chapter 9. Strategic Planning 91 L. Randy Strickland, EdD, OTR/L, FAOTA Chapter 10. Using Data to Guide Business Decisions 99 Carolyn Giordano, PhD, FASAHP Chapter 11. Risk Management and Contingency Planning Chapter 12. Marketing Strategies and Analysis Debi Hinerfeld, PhD, OTR/L, FAOTA Jessica McMurdie, OTR/L Chapter 4. Evolution and Future of Occupational Therapy Service Delivery Chapter 13. Building Capacity Chapter 5. Global Perspectives on Occupational Therapy Practice 89 Edited by Judith A. Parker Kent, OTD, EdS, OTR/L, FAOTA Chapter 3. Leadership vs. Management: Differences and Skill Sets Anne M. Haskins, PhD, OTR/L, and Debra J. Hanson, PhD, OTR/L, FAOTA 77 Debbie Amini, EdD, OTR/L, FAOTA, and Melissa Tilton, OTA, BS, COTA, ROH Sarah Corcoran, OTD, OTR/L 35 69 Ingrid M. Kanics, OTR/L, FAOTA Brent Braveman, PhD, OTR/L, FAOTA 27 59 Marla R. Robinson, MSc, OTR/L, BCPR, BT–C, FAOTA 107 121 133 Susan Touchinsky, OTR/L, SCDCM, CDRS Chapter 14. Starting New Programs 141 Ann Burkhardt, OTD, OTR/L, FAOTA 49 Elizabeth W. Stevens-Nafai, MSOT, CLT, and Said Nafai, OTD, OTR, CLT v Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] vi The Occupational Therapy Manager Chapter 15. Cultivating a Positive and Collaborative Workplace 153 Winnie Dunn, PhD, OTR, FAOTA; Timothy J. Wolf, OTD, PhD, OTR/L, FAOTA; Evan Dean, PhD, OTR/L; and Lindsey Jarrett, PhD Chapter 16. Promoting and Managing Diversity Edited by Shawn Phipps, PhD, OTR/L, FAOTA Chapter 24. Managing Quality and Promoting Evidence-Based Practice 159 Roxie M. Black, PhD, OTR, FAOTA Chapter 17. Volunteering: Staff Participation Outreach and Contributing to the Community 167 173 Edited by Roger I. Ideishi, JD, OT/L, FAOTA, and Albert E. Copolillo, PhD, OTR/L, FAOTA Chapter 18. Managing Organizational Change 175 Patricia Laverdure, OTD, OTR/L, BCP Chapter 19. Planning During Uncertainty 185 Jaime L. Smiley, MS, OTR/L, and Thomas Smith, MBA, OTR/L Chapter 20. Handling Resistance During Change Chapter 26. Evaluating Occupational Therapy Services and Client Satisfaction 251 Shawn Phipps, PhD, OTR/L, FAOTA Chapter 27. Measuring Outcomes 257 Chapter 28. Guidelines for Effective Documentation and Quality Reporting 269 Phuong Nguyen, OTD, OTR/L, CLT, Neuro–IFRAH® ­Certified Instructor, and Jess Anthony Holguin, OTD, OT/L Karen M. Sames, OTD, MBA, OTR/L, FAOTA Chapter 29. Federal Health Care Programs and Outcomes 193 Chapter 30. Private Health Insurance Chapter 21. Communicating During Change or Uncertainty Shawn C. Roll, PhD, OTR/L, RMSKS, FAOTA Chapter 31. Workers’ Compensation 201 Sheila Moyle, OTD, OTR/L, and Bridget Trivinia, OTD, MS, OTR/L 213 Roger I. Ideishi, JD, OT/L, FAOTA Sarah Bream, OTD, OTR/L 277 Jeremy R. Furniss, OTD, OTR/L, BCG Katie Jordan, OTD, OTR/L, and Sharmila Sandhu, JD Chapter 23. Becoming a Change Agent 243 Shawn Phipps, PhD, OTR/L, FAOTA, and Kathleen T. Foley, PhD, OTR/L, FAOTA Albert E. Copolillo, PhD, OTR/L, FAOTA, and Dianne F. Simons, PhD, OTR/L, FAOTA Chapter 22. Adding Value During Change 235 Pamela Roberts, PhD, OTR/L, SCFES, FAOTA, CPHQ, FNAP, FACRM; Maria Cecilia Alpasan, MA, OTR/L, CPHQ; and Ashley Uyeshiro Simon, OTD, OTR/L, MSCS Chapter 25. Understanding Client-Centered Practice Mary J. Hager, MA, OTR/L, FAOTA Section III. Navigating Change and Uncertainty Section IV. Outcomes and Documentation233 225 285 297 Chapter 32. Delivering Services Through Telehealth 311 Jana Cason, DHSc, OTR/L, FAOTA, and Tammy Richmond, MS, OTR/L, FAOTA Section V. Interprofessional Practice and Teams 319 Edited by Sarah McKinnon, OT, OTR, OTD, BCPR, MPA Chapter 33. Advocating Occupational Therapy’s Distinct Value Within Interprofessional Teams Craig E. Slater, PhD, MPH, BOccThy, and Anne Cusick, PhD, OTR(Australia) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 321 Contents Chapter 34. Supervising Other Disciplines 329 Debra Margolis, MS, OTR/L Chapter 35. Building Effective Teams 337 Regina Ferraro Doherty, OTD, OTR/L, FAOTA, FNAP Section VI. Supervision 343 Chapter 48. Understanding Economic and Political Trends 351 Sabrena McCarley, MBA–SL, OTR/L, CLIPP, RAC–CT, QCP Chapter 49. Designing a Payment Structure 357 Luis de Leon Arabit, OTD, MS, OTR/L, BCPR, C/NDT, PAM Chapter 39. Promoting Professionalism 369 Sean M. Getty, MS, OTR/L Chapter 40. Providing Constructive Feedback 377 Chapter 41. Working With Occupational Therapy Assistants 385 Heather Thomas, PhD, OTR/L 393 Melissa Tilton, OTA, BS, COTA, ROH, and Donna Costa, DHS, OTR/L, FAOTA Chapter 43. Management of Fieldwork Education 401 407 409 Melissa A. Plourde, OTR/L Chapter 45. Using Social Media Appropriately 449 451 457 465 Nathan B. Herz, OTD, MBA, OTR/L 471 Nathan B. Herz, OTD, MBA, OTR/L Chapter 52. Monitoring Cash Flow 477 Chuck Partridge, CPA Chapter 53. Professional Liability Insurance 505 Christopher M. Bluhm, CAE, CMA, CPA 511 Edited by Guy L. McCormack, PhD, OTR/L, FAOTA Edited by Karen Jacobs, EdD, OT, OTR, CPE, FAOTA Chapter 44. Communicating Across Generations and Cultures Chapter 50. Developing a Budget Section IX. Professional Standards Donna Costa, DHS, OTR/L, FAOTA Section VII. Communication 437 Ellen Hudgins, OTD, OTR/L, ITOT Chapter 51. Determining Costs for New Programs Jeanette Koski, OTD, OTR/L Chapter 42. Occupational Therapy Assistants as Managers Section VIII. Finance and Budgeting 345 Shawn Phipps, PhD, OTR/L, FAOTA Chapter 38. Mentoring and Motivating Others Chapter 47. Practitioner–Client Communication Edited by Nathan B. Herz, OTD, MBA, OTR/L Yvonne M. Randall, EdD, MHA, OTR/L, FAOTA Chapter 37. Conflict Resolution 427 Jessica J. Bolduc, DrOT, OTR/L, and Regula Robnett, PhD, OTR/L, FAOTA Tamera Keiter Humbert, DEd, OTR/L Edited by Donna Costa, DHS, OTR/L, FAOTA Chapter 36. Recruiting, Hiring, and Retaining Personnel Chapter 46. Grant Proposal Writing vii Chapter 54. Continuing Competence 513 Marla R. Robinson, MSc, OTR/L, BCPR, BT–C, FAOTA Chapter 55. Major Accrediting Organizations 521 Shawn Phipps, PhD, OTR/L, FAOTA Chapter 56. Accreditation Related to Education Winifred Schultz-Krohn, PhD, OTR/L, BCP, SWC, FAOTA 419 Amanda Nardone, OTS Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 529 viii The Occupational Therapy Manager Section X. Ethical and Legal Considerations537 Chapter 68. Returning to the Occupational Therapy Workforce Edited by Lea Brandt, OTD, MA, OTR/L Catherine C. Haines, OTR/L, and Stephanie Johnston, OTD, OTR, FAOTA Chapter 57. Organizational Ethics 539 Deborah Yarett Slater, MS, OT, FAOTA Chapter 58. Ethics in Fieldwork 547 Joanne Phillips Estes, PhD, OTR/L, and Leslie E. Bennett, OTD, OTR/L Chapter 59. Ethics for OTA Managers 555 Callie Schwartzkopf, OTD, OT/L, and Melissa Tilton, OTA, BS, COTA, ROH Chapter 60. Understanding the Law 565 571 Chapter 70. Becoming a Successful Contractor Chapter 72. Entrepreneurship Chapter 73. Why Is Policy Important? 589 Richard Y. Cheng, JD, MBA, OT/L, CHC, and Barbara L. Kornblau, JD, OTR/L, FAOTA, DASPE, CCM, CDMS, CPE Chapter 64. Understanding Employment Laws 597 Diane L. Smith, PhD, OTR/L, FAOTA, and Melanie Concordia, OTD, OTR/L Chapter 74. Regulatory and Payment Issues Mary Jo McGuire, MS, OTR/L, OTPP, FAOTA Chapter 76. Becoming an Advocate 609 695 707 617 Appendix A. Answers to Review Questions 715 Subject Index Citation Index 771 781 623 Edited by Karen Duddy, OTD, MHA, OTR/L Chapter 67. Succeeding as a New Leader or Manager 687 Elizabeth C. Hart, MS, OTR/L Kimberly S. Erler, PhD, OTR/L Section XI. Managing Your Career 677 Kristen Neville, MA, and Chuck Willmarth, CAE M. Beth Merryman, PhD, OTR/L, FAOTA Chapter 66. Moral Distress 675 Edited by Sarah McKinnon, OT, OTR, OTD, BCPR, MPA Chapter 75. State Regulation of Occupational Therapy Veda Collmer, JD, OTR/L Chapter 65. Addressing Health Disparities 667 Jayne Knowlton, OTD, OTR/L Chapter 62. Intellectual Property and Social Media Chapter 63. Billing for Occupational Therapy 659 Shain Davis, OTD, OTR/L Section XII. Public Policy 581 651 Shelley Margow, OTD, OTR/L Barbara L. Kornblau, JD, OTR/L, FAOTA, DASPE, CCM, CDMS, CPE Barbara L. Kornblau, JD, OTR/L, FAOTA, DASPE, CCM, CDMS, CPE 643 Tracy L. Witty, OTD, OTR/L, Reg.(OT), CLCP Chapter 71. Professional Development Barbara L. Kornblau, JD, OTR/L, FAOTA, DASPE, CCM, CDMS, CPE Chapter 61. Malpractice Chapter 69. Transitioning to New Practice Areas 633 625 Mandyleigh Smoot, MOT, OTR/L Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] About the Editors Karen Jacobs, EdD, OT, OTR, CPE, FAOTA, earned a doctoral degree at the University of Massachusetts in educational leadership in schooling, a master of science in occupational therapy at Boston University, and a bachelor of arts in psychology at Washington University in St. Louis. Karen is a past president and vice president of the American Occupational Therapy Association (AOTA). She has received 41 awards and honors, including Fulbright Scholarship to the University of Akureyri in Akuryeri, Iceland, in 2005; the Award of Merit from the Canadian Association of Occupational Therapists in 2009; the Award of Merit from AOTA in 2003; and the 2011 Eleanor Clarke Slagle Lectureship Award. Since completing her doctorate in 1993, Karen has authored, co-authored, edited, or co-edited more than 81 peer reviewed journal articles; 24 book chapters; and 24 books, such as Occupational Therapy Essentials for Clinical Competency (3 editions); The Occupational Therapy Manager; Ergonomics for Therapists (2 editions); Health Professional as Educator (2 editions); and Work Practice: International Perspectives. She is the co-author of 16 children’s books and hosts the podcast Lifestyle by Design. Karen is the founding editor-in-chief of the international, interprofessional journal, WORK: A Journal of Prevention, Assessment, and Rehabilitation (IOS Press, The Netherlands). She is the moderator of the complementary webinar series, Learn at WORK. Karen is a clinical professor of occupational therapy and the program director of the online postprofessional doctorate (OTD) in occupational therapy program at Boston University. She has worked at Boston University for 36 years and has expertise in the development and instruction of online graduate courses, use of technology to enable social participation among various populations of persons with disabilities, ergonomics, and health care marketing. She is a faculty-in-­ residence at Boston University, where she holds the weekly Sargent Choice Test Kitchen. Karen’s research examines the interface between the environment and human capabilities. In particular, she examines the individual factors and environmental demands associated with increased risk of functional limitations among various populations. Karen was the co-principal investigator for Project Career, a National Institute on Disability, Independent Living, and Rehabilitation Research 5-year interprofessional demonstration grant. To improve academic and employment outcomes for 2- and 4-year college students, including veterans with cognitive disabilities due to traumatic brain injury, Project Career integrates assistive technology and vocational rehabilitation to help students find accommodations that can help them be successful. This interdisciplinary initiative operated at Kent State University, Boston University, and West Virginia University, with its evaluation provided by JBS International. In addition to being an occupational therapist with 40 years of experience, Karen is a certified professional ergonomist; a fellow of the Human Factors ad Ergonomics Society (HFES); and is a consultant in ergonomics, marketing, and entrepreneurship. She is the chairperson of the Outreach Division and chairperson of the Environmental Design Technical Group of the HFES. Guy L. McCormack, PhD, OTR/L, FAOTA, has practiced as an occupational therapist for over 46 years. He started his college education by completing an associate degree in liberal arts with a focus on art and science. He enlisted in the U.S. Navy as a non-commissioned petty officer in the Seabees, where he served in military missions in Vietnam in support of the Marines and in civic action programs teaching construction skills to Vietnamese civilians. After receiving an honorable discharge, he worked as an occupational therapy assistant in a sheltered workshop in a psychiatric hospital in Upstate New York, where he developed a passion for discovering the value of occupation. He earned a bachelor of science degree in occupational therapy at the University of Puget Sound in Tacoma, WA, followed by his master of science degree from The Ohio State University in 1975. He received his doctorate in human science from Saybrook University in San Francisco in 1999. Guy started his teaching career at the University of Florida in Gainesville. He was recruited to teach at San Jose State University (SJSU), where he served for 16 years and became a tenured full professor. He was the founding program director for the occupational therapy program at Samuel Merritt University (SMU) in Oakland, CA. He practiced as an occupational therapist in home health in the San Francisco Bay area. He also served as the program director of the Occupational Therapy Program at the University of Missouri–Columbia. Guy returned to SMU as a teaching professor and contributed to the development of the occupational therapy doctoral degree program. Throughout his career, Guy has been active in state and national occupational therapy associations. He was Chair of Government Affairs when occupational therapists and occupational assistants became licensed in California. He served ix Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] x The Occupational Therapy Manager twice as vice president for the Occupational Therapy Association of California (OTAC). He has served on the Board for the American Occupational Political Action Committee. He also serves on multiple editorial boards. Guy has an active research agenda, ranging from studies in alternative and complementary interventions to integration of neuroscience evidence into occupational therapy practice. He has conducted grant-funded research on the use of computer-­ assisted neurofeedback training to ameliorate postcancer cognitive impairment in women with breast cancer, the effects of neurofeedback training on children with autism spectrum disorders, and cognitive functions in older adults. Guy’s scholarly publications have included book authorships on The Therapeutic Use of Touch for Health Professionals and Pain Management. He was the editor and co-editor for the 4th and 5th editions of The Occupational Therapy Manager, respectively. He has written 31 journal articles and chapters in peer-reviewed publications and has developed 10 audio–visual productions for teaching and learning modules for occupational therapy education. Guy has presented over 70 papers at state, national, and international conferences. Guy has received the rank of Professor Emeritus at SMU, the Lifetime Achievement Award by OTAC, congressional recognition for service to the community, the Award of Recognition for achieving occupational therapy licensure in California, appointment to the Roster of Fellows for the American Occupational Therapy Association, the OTAC Outstanding Service Award, the Joseph Picchi Memorial Lecture, the Strommen–Dillashaw Award at SMU, a graduate scholarship grant from California Foundation of Occupational Therapy, the Award of Merit from the Santa Clara Chapter of Occupational Therapy, and the Meritorious Performance Award at SJSU. Guy is currently an associate professor and the interim program director for the developing entry-level occupational therapy doctoral program at the University of the Pacific in Sacramento, CA. He resides in Seaside, California, in Monterey County, where he enjoys walks on the beach in Carmel by the Sea. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] About the Associate Editors and Contributors Maria Cecilia Alpasan, MA, OTR/L, CPHQ Quality and Education Coordinator Cedars–Sinai Los Angeles Debbie Amini, EdD, OTR/L, FAOTA Director of Professional Development American Occupational Therapy Association Bethesda, MD Luis de Leon Arabit, OTD, MS, OTR/L, BCPR, C/NDT, PAM Assistant Professor Department of Occupational Therapy College of Health and Human Sciences San Jose State University San Jose, CA Leslie E. Bennett, OTD, OTR/L Assistant Professor School of Health Sciences: Occupational Therapy Program The Sage Colleges Troy, NY Roxie M. Black, PhD, OTR, FAOTA Professor Emerita Occupational Therapy Program University of Southern Maine Lewiston Christopher M. Bluhm, CAE, CMA, CPA Chief Operating Officer American Occupational Therapy Association Bethesda, MD Jessica J. Bolduc, DrOT, OTR/L Adjunct Professor and Occupational Therapist University of New England Portland, ME Lea Brandt, OTD, MA, OTR/L Director MU Center for Health Ethics Executive Director Missouri Health Professions Consortium Associate Professional Practice Professor School of Medicine University of Missouri–Columbia Brent Braveman, PhD, OTR/L, FAOTA Director Department of Rehabilitation Services MD Anderson Cancer Center Houston Sarah Bream, OTD, OTR/L Associate Chair of Academic and Community Program Support and Development Associate Professor of Clinical Occupational Therapy Director of the Doctorate of Occupational Therapy Program Chan Division of Occupational Science and Occupational Therapy University of Southern California Los Angeles Ann Burkhardt, OTD, OTR/L, FAOTA Professor and Program Director Johnson and Wales University College of Health and Wellness Providence, RI Jana Cason, DHSc, OTR/L, FAOTA Professor Auerbach School of Occupational Therapy Spalding University Louisville, KY Richard Y. Cheng, JD, MBA, OT/L, CHC Partner DLA Piper, LLP Dallas xi Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] xii The Occupational Therapy Manager Veda Collmer, JD, OTR/L In-house Counsel, Chief Compliance Officer WebPT Phoenix Winnie Dunn, PhD, OTR, FAOTA Distinguished Professor University of Missouri Columbia Melanie Concordia, OTD, OTR/L Occupational Therapist University of Colorado Health at Memorial Hospital Central Colorado Springs Kimberly S. Erler, PhD, OTR/L Assistant Professor MGH Institute of Health Professions Boston Albert E. Copolillo, PhD, OTR/L, FAOTA Associate Professor and Chair Department of Occupational Therapy College of Health Professions Virginia Commonwealth University Richmond Joanne Phillips Estes, PhD, OTR/L Assistant Professor Department of Occupational Therapy Xavier University Cincinnati, OH Sarah Corcoran, OTD, OTR/L Assistant Professor Occupational Therapy Department University of the Sciences Philadelphia Donna Costa, DHS, OTR/L, FAOTA Program Director and Associate Professor University of Nevada, Las Vegas Anne Cusick, PhD, OTR(Australia) Professor and Chair of Occupational Therapy University of Sydney Professor Emeritus Wester Sydney University Australia Shain Davis, OTD, OTR/L Clinical Director of Related Services Achieve Beyond Pediatric Services Whittier, CA Evan Dean, PhD, OTR/L Assistant Professor Department of Occupational Therapy Education University of Kansas Kansas City Regina Ferraro Doherty, OTD, OTR/L, FAOTA, FNAP Associate Professor and Program Director Department of Occupational Therapy School of Health and Rehabilitation Sciences MGH Institute of Health Professions Boston Karen Duddy, OTD, MHA, OTR/L Occupational Therapy Supervisor Tibor Rubin VA Medical Center Long Beach, CA Kathleen T. Foley, PhD, OTR/L, FAOTA Associate Professor and Director, School of Occupational Therapy Ivester College of Health Sciences Brenau University Gainesville, GA Jeremy R. Furniss, OTD, OTR/L, BCG Director of Quality American Occupational Therapy Association Bethesda, MD Sean M. Getty, MS, OTR/L Clinical Assistant Professor and Site Coordinator Stony Brook Southampton Southampton, NY Carolyn Giordano, PhD, FASAHP Associate Provost, Institutional Effectiveness University of the Sciences Philadelphia Mary J. Hager, MA, OTR/L, FAOTA Occupational Therapist (Retired) Charleston, WV Catherine C. Haines, OTR/L Occupational Therapist Cambridge Health Alliance Cambridge, MA Debra J. Hanson, PhD, OTR/L, FAOTA Professor Academic Fieldwork Coordinator Occupational Therapy Department University of North Dakota Grand Forks Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] About the Associate Editors and Contributors Elizabeth C. Hart, MS, OTR/L Occupational Therapist Carol Woods Retirement Community Chapel Hill, NC Anne M. Haskins, PhD, OTR/L Associate Professor Occupational Therapy Department School of Medicine and Health Sciences University of North Dakota Grand Forks Nathan B. Herz, OTD, MBA, OTR/L Founding Director, OTD Program Presbyterian University Clinton, SC Debi Hinerfeld, PhD, OTR/L, FAOTA Clinical Assistant Professor Occupational Therapy Byrdine F. Lewis College of Nursing and Health Professions Georgia State University Atlanta Jess Anthony Holguin, OTD, OT/L Assistant Professor of Clinical Occupational Therapy Keck Medical Center of USC University of Southern California Los Angeles Ellen Hudgins, OTD, OTR/L, ITOT President Progressive Therapy Farmville, VA Leadership Elective Track Director Rocky Mountain University of Health Professions Provo, UT Tamera Keiter Humbert, DEd, OTR/L Associate Professor Chair and Program Director of Occupational Therapy Elizabethtown College Elizabethtown, PA Roger I. Ideishi, JD, OT/L, FAOTA Program Director and Professor Program in Occupational Therapy Temple University College of Public Health Philadelphia Karen Jacobs, EdD, OT, OTR, CPE, FAOTA Clinical Professor and Program Director Online Postprofessional Doctorate in Occupational Therapy Program Boston University xiii Lindsey Jarrett, PhD Senior Solution Strategist Intelligence Organization Cerner Corporation Kansas City, MO Stephanie Johnston, OTD, OTR, FAOTA Fieldwork Coordinator and Professor Occupational Therapy Assistant Program Occupational Therapy Practitioner Reentry Program Lone Star College–Tomball Tomball, TX Katie Jordan, OTD, OTR/L Professor of Clinical Occupational Therapy Associate Chair of Clinical Occupational Therapy Services Director of Occupational and Speech Therapy Hospital Practice Keck Hospital of USC; Norris Comprehensive Cancer Center Chan Division of Occupational Science and Occupational Therapy University of Southern California Los Angeles Ingrid M. Kanics, OTR/L, FAOTA President Kanics Inclusive Design Services, LLC New Castle, PA Judith A. Parker Kent, OTD, EdS, OTR/L, FAOTA Associate Professor Occupational Therapy Department University of the Sciences Philadelphia Jayne Knowlton, OTD, OTR/L Interim Director of Occupational Therapy Roberts Wesleyan College Rochester, NY Barbara L. Kornblau, JD, OTR/L, FAOTA, DASPE, CCM, CDMS, CPE Law Office of Barbara Kornblau Miami, FL Adjunct Occupational Therapy Faculty Florida A&M University Tallahassee Rocky Mountain University of the Health Professions Provo, UT Executive Director Coalition for Disability Health Equity Alexandria, VA Jeanette Koski, OTD, OTR/L Assistant Professor and Academic Fieldwork Coordinator University of Utah Salt Lake City Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] xiv The Occupational Therapy Manager Patricia Laverdure, OTD, OTR/L, BCP Assistant Professor Department of Occupational Therapy Virginia Commonwealth University Richmond Debra Margolis, MS, OTR/L Director Volunteer Services Spaulding Rehabilitation Hospital and Spaulding Hospital Cambridge Charlestown and Cambridge, MA Shelley Margow, OTD, OTR/L Clinical Director Georgia Developmental Services Roswell Sabrena McCarley, MBA–SL, OTR/L, CLIPP, RAC–CT, QCP Director of Quality RehabCare Napa, CA, and Louisville, KY Guy L. McCormack, PhD, OTR/L, FAOTA Professor Emeritus Samuel Merritt University Oakland, CA Mary Jo McGuire, MS, OTR/L, OTPP, FAOTA Director of Home and Community-Based Occupational Therapy Rehab Educators, LLC Akron, OH Sarah McKinnon, OT, OTR, OTD, BCPR, MPA Lecturer Boston University Jessica McMurdie, OTR/L Owner and Clinical Director Stepping Stones Therapy Network Bellevue, WA Integrated Developmental Center Bothell, WA M. Beth Merryman, PhD, OTR/L, FAOTA Professor and Chairperson Department of Occupational Therapy and Occupational Science Towson University Towson, MD Sheila Moyle, OTD, OTR/L Assistant Professor and Academic Fieldwork Coordinator Occupational Therapy Program Temple University Philadelphia Said Nafai, OTD, OTR, CLT President Occupational Therapy Association of Morocco Assistant Professor School of Health Sciences, Division of Occupational Therapy American International College Springfield, MA Amanda Nardone, OTS Occupational Therapy Student Boston University Kristen Neville, MA Manager, State Affairs American Occupational Therapy Association Bethesda, MD ® Phuong Nguyen, OTD, OTR/L, CLT, Neuro–IFRAH Certified Instructor Assistant Director of Clinical Occupational Therapy Associate Professor of Clinical Occupational Therapy Keck Medical Center of USC USC Norris Comprehensive Cancer Center University of Southern California Los Angeles Chuck Partridge, CPA Chief Financial Officer American Occupational Therapy Association Bethesda, MD Shawn Phipps, PhD, OTR/L, FAOTA Chief Quality Officer Associate Hospital Administrator Rancho Los Amigos National Rehabilitation Center Downey, CA Adjunct Faculty and Board of Councilors Chan Division of Occupational Science and Occupational Therapy University of Southern California Los Angeles Melissa A. Plourde, OTR/L Department Supervisor of Occupational Therapy Regional School Unit 73 Towns of Jay, Livermore Falls, and Livermore, ME Yvonne M. Randall, EdD, MHA, OTR/L, FAOTA Associate Dean College of Health and Human Services Touro University Nevada Henderson Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] About the Associate Editors and Contributors Tammy Richmond, MS, OTR/L, FAOTA President and Chief Executive Officer Go 2 Care, Inc. Los Angeles Pamela Roberts, PhD, OTR/L, SCFES, FAOTA, CPHQ, FNAP, FACRM Executive Director and Professor, Physical Medicine and Rehabilitation Executive Director, Academic and Physician Informatics Cedars–Sinai Los Angeles Marla R. Robinson, MSc, OTR/L, BCPR, BT–C, FAOTA Assistant Director Inpatient Therapy Services University of Chicago Medicine Chicago Regula Robnett, PhD, OTR/L, FAOTA Professor University of New England Portland, ME Shawn C. Roll, PhD, OTR/L, RMSKS, FAOTA Associate Professor Director of the PhD in Occupational Science Chan Division of Occupational Science and Occupational Therapy University of Southern California Los Angeles Karen M. Sames, OTD, MBA, OTR/L, FAOTA Professor of Occupational Therapy St. Catherine University St. Paul, MN Sharmila Sandhu, JD Counsel and Director of Regulatory Affairs American Occupational Therapy Association Bethesda, MD Winifred Schultz-Krohn, PhD, OTR/L, BCP, SWC, FAOTA Professor and Chairperson Occupational Therapy Department San Jose State University San Jose, CA Callie Schwartzkopf, OTD, OT/L Occupational Therapy Assistant Program Director Central Community College Grand Island, NE Ashley Uyeshiro Simon, OTD, OTR/L, MSCS Associate Professor of Clinical Occupational Therapy Chan Division of Occupational Science and Occupational Therapy University of Southern California Los Angeles Dianne F. Simons, PhD, OTR/L, FAOTA Assistant Professor Department of Occupational Therapy College of Health Professions Virginia Commonwealth University Richmond Craig E. Slater, PhD, MPH, BOccThy Director, Interprofessional Education and Practice College of Health and Rehabilitation Sciences: Sargent College Boston University Deborah Yarett Slater, MS, OT, FAOTA Consulting Practice Manager, Ethics American Occupational Therapy Association Bethesda, MD Jaime L. Smiley, MS, OTR/L Clinical Education Coordinator Medical Facilities of America Roanoke, VA Adjunct Faculty Department of Occupational Therapy Virginia Commonwealth University Richmond Diane L. Smith, PhD, OTR/L, FAOTA Professor and Doctoral Capstone Coordinator MGH Institute of Health Professions Boston Thomas Smith, MBA, OTR/L Chief Operating Officer MossRehab/Einstein Elkins Park Elkins Park, PA Mandyleigh Smoot, MOT, OTR/L Assistant Chief of Physical Medicine and Rehabilitation Veterans Affairs Medical Center Minneapolis Elizabeth W. Stevens-Nafai, MSOT, CLT Occupational Therapist Worcester Public Schools Worcester, MA Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] xv xvi The Occupational Therapy Manager Virginia “Ginny” Stoffel, PhD, OT, FAOTA Associate Professor and Associate Program Director Department of Occupational Science and Technology University of Wisconsin–Milwaukee L. Randy Strickland, EdD, OTR/L, FAOTA Professor of Occupational Therapy Auerbach School of Occupational Therapy Spalding University Louisville, KY Heather Thomas, PhD, OTR/L Professor West Coast University Los Angeles Melissa Tilton, OTA, BS, COTA, ROH Clinical Operations Area Director Genesis Rehab Services Saugus, MA Adjunct Faculty North Shore Community College Danvers, MA Bridget Trivinia, OTD, MS, OTR/L Academic Fieldwork Coordinator and Clinical Assistant Professor Occupational Therapy Program Widener University Chester, PA Chuck Willmarth, CAE Associate Chief Officer, Health Policy and State Affairs American Occupational Therapy Association Bethesda, MD Tracy L. Witty, OTD, OTR/L Reg.(OT), CLCP Director of Occupational Therapy and Life Planner Turning Point Rehabilitation Consulting, Inc. Vancouver, BC, and Palm Desert, CA Timothy J. Wolf, OTD, PhD, OTR/L, FAOTA Associate Professor and Chair Department of Occupational Therapy University of Missouri Columbia Susan Touchinsky, OTR/L, SCDCM, CDRS Occupational Therapy Certified Driver Rehabilitation Specialist and Owner Adaptive Mobility Services, LLC Orwigsburg, PA Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] List of Figures, Tables, Exhibits, Case Examples, and Appendixes Figures Figure 2.1. A sample and abbreviated organizational chart�������������������������������������������������������������������������� 20 Figure 2.2. F ishbone diagram on causes for extended time to receive and schedule initial evaluations............................................................... 24 Figure 4.1. Occupational therapy employment by setting������������������������������������������������������������������ 40 Figure 8.1. Occupational therapy domain and process......... 79 Figure 8.2. C ircumplex of change recipients’ responses to change and underlying core affect................... 82 Figure 8.3. Model of responses to change............................... 83 Figure 9.1. Strategic planning cycle.......................................... 94 Figure 10.1. Dashboard example............................................. 103 Figure 11.1. H ealth care risk management events in the United States, 1980–2015.................................... 109 Figure 11.2. Sample risk matrix...............................................111 Figure 11.3. Example of root cause analysis for a witnessed fall.........................................................114 Figure 12.1. The 7 Ps of marketing......................................... 123 Figure 18.1. Kotter’s 8 steps of change................................... 178 Figure 21.1. Sample organizational structure....................... 202 Figure 21.2. Stakeholder map.................................................. 205 Figure 22.1. Eleanor Clarke Slagle.......................................... 219 Figure 23.1. C ore Centennial Float Committee Members, 2011–2017, and change agents in the early stages of the float’s building process������������������������������������������������������������������ 228 Figure 23.2. The float Celebrating a Century of Occupational Therapy during the Annual Tournament of Roses Parade on January 1, 2017.................................................... 229 Figure 24.1. The IHI Triple Aim............................................. 236 Figure 24.2. The Donabedian model of patient safety......... 237 Figure 25.1. C ore components of client-centered and patient-centered care...........................................244 Figure 27.1. C ategories of quality measures listed in the National Quality Measures Clearinghouse...................................................... 259 Figure 27.2. ICHOM standard set for dementia................... 260 Figure 29.1. The National Quality Strategy........................... 279 Figure 30.1. Percentage of people by type of health insurance coverage and change from 2013 to 2016.......................................................... 286 Figure 30.2. H ealth insurance coverage of children, 2015...................................................... 294 Figure 54.1. K nowledge translation: What it is and what it isn’t����������������������������������������������������514 Figure 59.1. Tip box������������������������������������������������������������������ 556 Figure 71.1. Standards for continuing competence............. 660 Figure 73.1. Steps of the policy process.................................. 678 Figure 74.1. The service-payment cycle: Provision of OT services to reimbursement.......................... 688 Tables Table 2.1. Commonly Used Tools and Techniques in Continuous Quality Improvement......................... 23 Table 3.1. Complementary Process Differences Between Leaders and Managers.............................. 29 Table 4.1. Types of Health Care Organizations ..................... 36 Table 4.2. Medicare, Medicaid, and CHIP Overview............ 37 Table 4.3. Legislative Influence on Service Provision............ 38 Table 4.4. Emerging Niche Practice Areas.............................. 41 Table 6.1. C riteria for Trustworthy Clinical Practice Guidelines................................................... 64 Table 11.1. R isk Management Strategies and Guiding Questions.................................................110 Table 11.2. O ccupational Therapy Skills and Risk Management Strategies........................................ 115 Table 13.1. Steps for Developing Capacity............................. 137 Table 16.1. Racial Demographic Trends in the United States, 1975–2065 by Percentage of Population............................................................... 160 Table 16.2. Cultural Functions of Managers......................... 162 Table 18.1. Key Theories, Frameworks, and Models That May Have Utility in Implementing Change in Occupational Therapy Organizations, Programs, and Staff................... 177 Table 18.2. Steps Taken to Support Change in Practice ..... 182 Table 21.1. Characteristics of 3 Leadership Styles ............... 208 Table 22.1. Client-Centered Strategies Framework...............214 Table 22.2. Sample Person-, Population-, OrganizationLevel Occupational Therapy Needs.................... 217 Table 22.3. Sample Person, Population, and Organizational Intervention Plan...................... 218 Table 27.1. Measurement Properties ...................................... 262 Table 27.2. Assessing Existing Tools...................................... 265 Table 27.3. Measurement Resources....................................... 265 Table 29.1. R esources for Current Federal Programs and Outcomes........................................................ 280 Table 30.1. Several Common Managed Care Plans ............ 287 xvii Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] xviii The Occupational Therapy Manager Table 33.1. Key Characteristics of Multidisciplinary and Interprofessional Teams................................ 323 Table 34.1 E thical and Core Values of Allied Health Professions............................................................... 331 Table 35.1. Responsibilities of Effective Team Leaders........ 340 Table 39.1. Stage-Specific Strategies for Promoting Professionalism...................................................... 372 Table 44.1. Generational Differences..................................... 413 Table 45.1. Social Media Platforms......................................... 420 Table 47.1. F ocus of Practitioner–Client Communication as Represented in AJOT, 1950–Present.......................................................... 439 Table 47.2. Ethical Considerations Related to Practitioner–Client Communication................. 441 Table 47.3. Difficult or Challenging Conversations and Suggested Strategies......................................443 Table 65.1. O ccupational Therapy Provider Demographics........................................................ 613 Table 67.1. Turning Leadership Challenges Into Treatment Plans..................................................... 627 Table 73.1. AOTA Policy Resources....................................... 679 Table 73.2. T ypes of Policies and Overlap With Areas of Occupation........................................................ 680 Exhibits Exhibit 4.1. Policy Learning Activity....................................... 39 Exhibit 4.2. H ow the Judicial Branch Can Affect Health Care ........................................................... 39 Exhibit 5.1. Terms Related to Cultural Relevance.................. 50 Exhibit 7.1. AOTA-Defined Emerging Practice Areas.......... 70 Exhibit 9.1. SWOT Analysis for Proposed Hand Rehabilitation Program......................................... 93 Exhibit 10.1. Research Plan ..................................................... 101 Exhibit 10.2. Questions to Ask a Data Scientist................... 104 Exhibit 11.1. Description of Enterprise Risk Domains..................................................... 108 Exhibit 11.2. Dos and Don’ts for Incident Reporting ..........111 Exhibit 11.3. Sample Risk Report........................................... 113 Exhibit 12.1. Marketing Examples......................................... 124 Exhibit 12.2. Target Market Areas......................................... 124 Exhibit 12.3. Environmental Assessment Factors............... 125 Exhibit 12.4. Marketing Plan Key Components................... 125 Exhibit 12.5. Internet and Social Media Channels for Marketing........................................................... 128 Exhibit 14.1. T ypical Sections of a Policy and Procedures Manual............................................ 145 Exhibit 14.2. Practical Considerations for Starting New Programs.................................................... 150 Exhibit 16.1. N ational CLAS Standards in Health and Health Care......................................................... 161 Exhibit 16.2. E xample of an Organization’s Value Statement............................................................ 163 Exhibit 22.1. Sample Stakeholder Mapping: Prioritizing Value, Needs, and Actions Through Stakeholder Mapping........................ 216 Exhibit 23.1. Qualities of an Effective Change Agent.......... 226 Exhibit 24.1. QAPI Plan Project Template............................ 237 Exhibit 24.2. Sustainment Plan Example.............................. 239 Exhibit 30.1. C hecklist of Key Questions to Ask About Insurance Plan Coverage ............. 293 Exhibit 32.1. Key Telehealth Resources................................. 315 Exhibit 33.1. Occupational Therapy Code of Ethics References to Interprofessional Collaborative Practice....................................... 324 Exhibit 34.1. E xamples of Behavioral Interviewing Questions.................................... 332 Exhibit 35.1. Key Elements of Effective Teams..................... 339 Exhibit 38.1. Common Mentor and Mentee Benefits.......... 358 Exhibit 44.1. R eflective Activity: Cultural Awareness........ 411 Exhibit 45.1. Social Media Tips............................................... 421 Exhibit 46.1. Steps of Grant Proposal Writing..................... 428 Exhibit 46.2. Timeline Template............................................ 431 Exhibit 46.3. Budget Template................................................ 432 Exhibit 46.4. 11 Key Steps in Grant Writing......................... 433 Exhibit 48.1. Great Recession Effects .................................... 452 Exhibit 50.1. O ccupational Therapy Clinic Cost Breakdown.................................................466 Exhibit 51.1. P roforma Neurology Start-Up (First Year)........................................................... 472 Exhibit 51.2. Revenue Calculation......................................... 473 Exhibit 51.3. Short-Form Calculation.................................... 473 Exhibit 51.4. Long-Form Calculation.................................... 473 Exhibit 51.5. Neurology Start-up Budget.............................. 474 Exhibit 57.1. Framework for Ethical Decision Making....... 541 Exhibit 57.2. AOTA Ethics Publications................................ 541 Exhibit 68.1. The Value of Returning Practitioners............. 634 Exhibit 68.2. Survey: Reentry Into the Occupational Therapy Workforce.................. 634 Exhibit 68.3. A OTA’s Guidelines for Reentry Into the Field of Occupational Therapy......................... 637 Exhibit 68.4. Reentry and Refresher Courses....................... 638 Exhibit 68.5. Self-Care and Stress Management.................. 638 Exhibit 69.1. Internal and External Factors Leading to Overall Retention...............................................644 Exhibit 70.1. Reflective Questions to Ask When Considering Working as a Contractor........... 652 Exhibit 70.2. I RS Multifactor Test: Employee or Independent Contractor?................................. 653 Exhibit 74.1. C ritical CMS Excerpts Related to What Constitutes Reasonable and Necessary Skilled Therapy ............................... 689 Exhibit 75.1. AOTA’s Model Practice Act’s Definition of Occupational Therapy................................... 699 Exhibit 75.2. State Regulation Online Resources................. 700 Exhibit 76.1. E xamples of Advocacy at the Daily Practice Level........................................... 708 Exhibit 76.2. Examples of Advocacy at the Professional Level.............................................. 708 Exhibit 76.3. E xamples of Advocacy at the Systems Level...................................................... 709 Exhibit 76.4. Writing to Elected Representatives................. 710 Exhibit 76.5. S ample Phone Call to a Member of Congress......................................... 710 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] List of Figures, Tables, Exhibits, Case Examples, and Appendixes Exhibit 76.6. Dos and Don’ts When Meeting With Elected Officials................................................. 711 Exhibit 76.7. T ips for Building Relationships With Elected Officials.................................................. 711 Case Examples Case Example 1.1. Ginny Stoffel’s Leadership Journey........... 7 Case Example 2.1. R obin: Starting as a New Occupational Therapy Manager.............. 24 Case Example 3.1. B alancing the Roles of Leader and Manager ................................. 32 Case Example 4.1. E xploring Stakeholders and Partnerships for New Programming.................................... 45 Case Example 5.1. International Opportunities: Morocco....................................................... 54 Case Example 5.2. D omestic Cultural Experience................ 55 Case Example 5.3. S upporting Refugees at Home................. 55 Case Example 6.1. Acute Care Readmissions......................... 65 Case Example 7.1. A llison: An Occupational Therapy Twist on a Travel Business........................ 74 Case Example 7.2. Megan: Creating an Inclusive Swimming Program for Children With ASD and SPD....................................................... 74 Case Example 8.1. New Manager and a Paradigm Shift....... 85 Case Example 9.1. M ount View Hospital Transformation........................................... 95 Case Example 10.1. J anelle: A School District Manager Needs to Review..................................... 104 Case Example 11.1. H ome Health Agency Risk Management ................................. 112 Case Example 11.2. Julia: New Private Outpatient Practice ................................117 Case Example 11.3. Managing Risk in School Settings.......117 Case Example 12.1. C onducting an Organizational Assessment.............................................. 130 Case Example 13.1. B uilding Capacity to Improve Driving and Community Mobility Services.................................... 138 Case Example 14.1. Starting Programs in Clinical Settings..................................... 143 Case Example 14.2. S tarting Educational Programs........... 146 Case Example 15.1. Strengths-Based Leadership in Fieldwork Supervision...................... 157 Case Example 15.2 S trengths-Based Leadership in a Research Team................................. 157 Case Example 15.3. S trengths-Based Leadership in an Academic Department................ 157 Case Example 16.1. S arah: Managing Diversity................... 165 Case Example 17.1. Braille Trail.............................................. 168 Case Example 17.2. C hallenger Baseball............................... 168 Case Example 17.3. W orking With Veterans and Young Adults With Disabilities........... 169 Case Example 17.4. Love of Nature........................................ 169 Case Example 17.5. National Volunteer Opportunity......... 170 Case Example 17.6. Learning New Skills............................... 170 Case Example 17.7. Day at the Legislature............................ 171 xix Case Example 18.1. B uilding a Culture of Knowledge Translation in a School Setting ........... 181 Case Example 19.1. Payment Methodology Adaptation..... 190 Case Example 20.1. C reating a New Evaluation Process................................. 197 Case Example 21.1. Communicating During Change........ 209 Case Example 22.1. Person, Population, and Organizational Perspectives ........ 220 Case Example 23.1. C elebrating a Century of Occupational Therapy........................... 228 Case Example 24.1. Process Improvement Model............... 240 Case Example 24.2. Outcome Measurement Model............ 241 Case Example 25.1. Lynn: Client-Centered Practice........... 247 Case Example 26.1. Client-Centered Evaluation.................. 254 Case Example 27.1. D emonstrating Value in an Evolving Reimbursement Landscape .................. 266 Case Example 28.1. Hannah’s Documentation Challenge................................................ 274 Case Example 29.1. Quality Improvement in a Skilled Nursing Facility Under Medicare........ 283 Case Example 30.1. Navigating the Maze of Private Health Insurance................................... 292 Case Example 31.1. Best Practices for Managing a Workers’ Compensation Claim............ 306 Case Example 32.1. Telehealth Program Development....... 315 Case Example 33.1. E stablishing a New Occupational Therapy Service...................................... 326 Case Example 34.1. Supervising Interdisciplinary Teamwork............................................... 334 Case Example 35.1. Patrice: Intra- and Interprofessional Communication..................................... 341 Case Example 36.1. Kids Therapy Seeks New Therapist..... 349 Case Example 37.1. Conflict Resolution................................ 354 Case Example 38.1. Mary: New Occupational Therapy Manager................................... 364 Case Example 39.1. D eveloping Staff Professionalism in a Rehabilitation Setting......................... 374 Case Example 40.1. Application of the Reflective Model of Feedback................................. 382 Case Example 41.1. Joe: Evaluation Process Challenge....... 386 Case Example 41.2. Consuela: Levels of Supervision.......... 388 Case Example 42.1. S haron: First Steps as an OTA Manager......................................... 399 Case Example 43.1. S usan: Beginning Fieldwork Education................................................ 405 Case Example 44.1. Thomas: Generation Z.......................... 416 Case Example 45.1. Project Career and Social Media......... 425 Case Example 46.1. Zoey: Prevention and Wellness........... 433 Case Example 46.2. Acquired Brain Injury Community Program........................... 434 Case Example 47.1. Stephanie, Jenny, and Mrs. White: Communication and Empathy.............444 Case Example 48.1. Maria: Chronic Pain.............................. 456 Case Example 49.1. Ms. Jones: Bundled Care....................... 463 Case Example 50.1. Developing a Budget..............................466 Case Example 51.1. Calculating Staffing and Space for a Hospital Clinic.................... 475 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] xx The Occupational Therapy Manager Case Example 53.1. W orking Outside the Accepted Scope of Practice .................. 506 Case Example 53.2. Unattended Child Falls Off a Swing.............................................. 507 Case Example 53.3. Injury During Electrotherapy.............. 507 Case Example 53.4. S tudent Intern Injured by Equipment............................................... 508 Case Example 54.1. C raig: Continuing Competence ........................................... 518 Case Example 55.1. K aren: Preparing for an Onsite Survey Visit................................ 528 Case Example 56.1. I nternal Institutional Review Process....................................... 534 Case Example 57.1. P ower Differentials Within the Health Care Team..................................542 Case Example 57.2. Competing Goals................................... 543 Case Example 57.3. Uphold the Code or Comply With the Directive?................................544 Case Example 58.1. Sally: Level II Fieldwork........................ 552 Case Example 59.1. Becky and Roshni: Daily Life of an OTA Manager................................... 558 Case Example 59.2. L indee: Articulating the Role of an OTA Manager............................... 559 Case Example 59.3. G oing Through the Decision-Making Process..................... 560 Case Example 62.1. Lela: Social Media and Intellectual Property���������������������������� 586 Case Example 64.1. Understanding Employment Laws......606 Case Example 65.1. Addressing Health Disparities..............614 Case Example 66.1. Moral Distress in Inpatient Acute Care............................. 620 Case Example 67.1. Adele’s Leadership Journey................... 630 Case Example 68.1. Returning to the Occupational Therapy Workforce................................ 639 Case Example 69.1. Diane: Exploring Mental Health.........646 Case Example 69.2. R obert: Public Health to Private Practice......................................646 Case Example 69.3. Kate: Seeking Direct Treatment Opportunities.........................................648 Case Example 70.1. Jane: Working as a Contractor............. 654 Case Example 70.2. J enny: Calculating Take-Home Pay...................................... 656 Case Example 70.3. Tom: Changing W-2 Status����������������� 657 Case Example 71.1. Luke: New Practitioner Professional Development.................... 665 Case Example 72.1. AquaEve.................................................. 672 Case Example 73.1. Alice: Home Health Advocacy............. 683 Case Example 74.1. Preauthorization.................................... 693 Case Example 75.1. How Do I Obtain a License?................. 704 Case Example 76.1. Camille: Advocating for Occupational Therapy........................... 712 Appendixes Appendix 1.1. Values Card Sort Activity................................... 9 Appendix 5.A. WFOT Disaster Preparedness and Response Position Statement......................... .58 Appendix 11.A. Risk Management Resources...................... 120 Appendix 23.A. Change Analysis........................................... 232 Appendix 25.A. AOTA’s Occupational Profile Template.......249 Appendix 46.A. Sample Cover Letter.................................... 435 Appendix 52.A. AOTA’s Financial Statements..................... 485 Appendix 54.A. A OTA Standards for Continuing Competence............................ 520 Appendix 58.A. SWOT Analysis to Examine an Organization’s Ability to Participate in Fieldwork Education............................... 554 Appendix 58.B. Role-Play Activity......................................... 554 Appendix 59.A. Ethics Resources for OTA Managers........... 563 Appendix 68.A. Reentry Into the Occupational Therapy Workforce�������������������������������������642 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Note From the Publisher When I first arrived at the American Occupational Therapy Association (AOTA) nearly 2 decades ago, one of the first texts that greeted me on my desk was the 4th Edition of The Occupational Therapy Manager (McCormack et al., 2003). I had page proofs to review, and that close read provided a crash course on the occupational therapy profession, information that I then used with our publishing team to restart an idling book program. Since then, each revision has become even more robust, like occupational therapy itself, and as the publisher I am pleased to say that over its history, this book has consistently captured a large share of the marketplace. But most importantly, since the inaugural edition’s publication in the mid-1980s (Bair & Gray, 1985; see also Bair & Gray, 1992; Bair, 1996; Jacobs & McCormack, 2011), this book has reflected expanding opportunities for OTs and OTAs to lead not only members of their own profession but also within health care and education in general. We have seen how management, administration, and leadership have become more complicated over the years, and it is important for occupational therapy students, practitioners, managers, and leaders to be fluent in the topics discussed in this book. For this 6th edition, AOTA Press sought to combine timetested thought leaders with new authors, allowing for more diverse perspectives on the issues while creating an upward ladder for future editorial leadership. We hope that readers will agree that this seems to have worked well and has generated a more comprehensive collection of chapters. As I (along with my Communications colleagues) have said over the years to countless students and new practitioners in our AOTA Annual Conference presentation and as I have counseled long-time leaders over many publishing projects, “you’ve got this,” and occupational therapy professionals at all career levels should feel confident telling their story (see Whitney & Davis, 2013). We are pleased to have representation from a wide range of generational cohorts in this book to match those in the occupational therapy workforce. In addition, we have broken down the 76 chapters—the largest edition ever— to focus more closely on essential considerations and practical applications, recognizing that today everyone is challenged for time in consuming and understanding an overload of information. We also have several non–occupational therapy professionals who have applied their unique wisdom and skill sets in service of teaching on a wide range of management topics. This edition reflects the work of not only the editors and authors, who are listed in the front matter and whose stellar work has eclipsed our expectations, but also of AOTA staff from across the association who have either written or performed peer review on this work—or both—under the guise of “other duties as assigned” or by taking vacation days (now that is dedication!) to help. They are acknowledged here, in alphabetical order: Debbie Amini, Christopher Bluhm, Chris Davis, Barb Dickson, Jeremy Furniss, Frank Gainer, Neil Harvison, Ashley Hofmann, Christina Metzler, Kristen Neville, Heather Parsons, Chuck Partridge, Maureen Peterson, Sabrina Salvant, Sharmila Sandhu, Deborah Slater, Chuck Willmarth, and Monica Wright. As change in continues to advance exponentially throughout the world, we are confident that there will be as-yet-­ unimagined topics to discuss in a future 7th edition. Perhaps some of you reading this book will step up to contribute! —Christina A. Davis Associate Chief Officer, AOTA Press & Content Strategy American Occupational Therapy Association Bethesda, MD REFERENCES Bair, J., & Gray, M. (Eds.). (1985). The occupational therapy manager. Rockville, MD: American Occupational Therapy Association. Bair, J., & Gray, M. (Eds.). (1992). The occupational therapy manager (rev. ed.). Rockville, MD: American Occupational Therapy Association. Bair, J. (Ed.). (1996). The occupational therapy manager (rev. ed.). Bethesda, MD: American Occupational Therapy Association. McCormack, G. L., Jaffe, E. G., & Goodman-Lavey, M. (Eds.). (2003). The occupational therapy manager (4th ed.). Bethesda, MD: AOTA Press. Jacobs, K., & McCormack, G. L. (Eds.). (2011). The occupational therapy manager (5th ed.). Bethesda, MD: AOTA Press. Whitney, R. V., & Davis, C. A. (Eds.). (2013). A writer’s toolkit for occupational therapy and health care professionals: An insider’s guide to writing, communicating, and getting published. Bethesda, MD: AOTA Press. xxi Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Introduction Karen Jacobs, EdD, OT, OTR, CPE, FAOTA; Guy L. McCormack, PhD, OTR/L, FAOTA; Judith A. Parker Kent, OTD, EdS, OTR/L, FAOTA; Albert E. Copolillo, PhD, OTR/L, FAOTA; Roger I. Ideishi, JD, OT/L, FAOTA; Shawn Phipps, PhD, OTR/L, FAOTA; Sarah McKinnon, OT, OTR, OTD, BCPR, MPA; Donna Costa, DHS, OTR/L, FAOTA; Nathan B. Herz, OTD, MBA, OTR/L; Lea Brandt, OTD, MA, OTR/L; and Karen Duddy, OTD, MHA, OTR/L OVERVIEW OF THE OCCUPATIONAL THERAPY MANAGER, 6TH EDITION In today’s health care environment, occupational therapy managers and leaders must be prepared to ensure that high-­quality care is delivered; staff morale and efficiency remain high; businesses and organizations are profitable; and the profession is recognized by other health care professionals, reimbursers, and clients as a valuable service steeped in evidence. This new edition of The Occupational Therapy Manager takes this charge seriously, greatly expanding the areas and topics covered. This new edition has 76 chapters and is organized by 12 sections: ■ Section I. Foundations of Occupational Therapy Leader■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ship and Management Section II. Organizational Planning and Culture Section III. Navigating Change and Uncertainty Section IV. Outcomes and Documentation Section V. Interprofessional Practice and Teams Section VI. Supervision Section VII. Communication Section VIII. Finance and Budgeting Section IX. Professional Standards Section X. Ethical and Legal Considerations Section XI. Managing Your Career Section XII. Public Policy These sections are designed to address the importance of good leadership through economic, political, and cultural changes as well as the practical aspects of day-to-day management. Chapters include learning objectives, key terms and concepts, essential considerations and practical applications in occupational therapy, a case example, and relevant ACOTE Standards. Learning activities and review questions challenge the reader’s understanding and application of the concepts. Throughout the text, authors across practice areas and settings provide strategies on the how-to aspects of business administration and program development while emphasizing occupational therapy’s distinct role and value. Promoting the profession through capable and effective leadership results in high-quality service delivery, better client outcomes, successful reimbursement, and wider recognition of the value occupational therapy. SECTION I. FOUNDATIONS OF OCCUPATIONAL THERAPY LEADERSHIP AND MANAGEMENT There is not one way to be a leader, and readers will find themselves leading in different ways, depending on where they are, who they are around, and what role they are filling. Leadership is not simply an innate characteristic; it is a skill that requires self-awareness and practice. Section I, “Foundations of Occupational Therapy Leadership and Management,” contains 8 chapters that examine broad ideas of leadership, the skills of management, and the role of occupational therapy practitioners as leaders in established health care systems, in emerging areas of practice, and across the globe. It introduces relevant theories of leadership and uses a comparison of servant, transactional, and transformational leadership to challenge readers in thinking about their own leadership approach. This section sets you up to begin thinking about and developing your personal leadership trajectory and action plan. Opportunities to develop leadership skills are introduced, and details are presented about AOTA’s Emerging Leadership Development Program and Middle Manager and Executive Leadership Institute Programs. You are called to action! Perspectives on management are introduced to identify and explain the commonly identified key functions of a manager. Examples of how occupational therapy managers are involved in management development and assessment of competency, marketing, program development, and continuous quality improvement are described in this section. Readers are challenged to explore the relationship among leaders, management, and supervision. SECTION II. ORGANIZATIONAL PLANNING AND CULTURE The term organization gives the sense of a single entity that exists in its own right and is more than the people and parts that make it up. However, each organization has a culture or sense of identity that is created and actualized by each of the organization’s xxiii Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] xxiv The Occupational Therapy Manager members, internal groups, and departments (Doorewaard & Benschop, 2002). How do these individuals, groups, and departments form and continue the organization’s existence? Section II, “Organizational Planning and Culture,” contains 9 chapters that examine how culture is formed and, with this sense of identity, how an organization plans for and actualizes its future. It explores how a strategic plan evolves as a guide and data are used for decision-making. The many challenges that affect evolving organizations are examined through the lens of risk management. Improving outcomes through capacity building and program development, and how to market them, are explored. Chapters devoted to fostering collaboration, diversity, and volunteering remind readers that organizations are ultimately made of up people. Organizational culture matters. Multiple approaches and ways of thinking can support an organization’s flexibility in continually changing internal and external environments. SECTION III. NAVIGATING CHANGE AND UNCERTAINTY Change occurs on a daily basis. Change and uncertainty have garnered substantial attention in the health care industry in recent years. During organizational change, stakeholders need to know that change is coming, why the changes are being made, what the implementation plan is, and that leadership is supportive of staff. Section III, “Navigating Change and Uncertainty,” contains 6 chapters that examine how to manage organizational change, which is influenced by regulatory, policy, and payment reforms that value high-quality, client-centered care and reproducible cost-efficient results. Occupational therapy managers are challenged to lead change and innovation in health, education, and social systems without compromising care and service delivery. Planning during uncertainty is challenging. This section is intended to help occupational therapy managers create new word associations when faced with uncertainty and explore approaches for dealing with uncertainty where team members can recognize and analyze their perceptions. Managers can then objectively explore alternative perspectives for approaching and planning during uncertainty. Change always brings resistance, so minimizing the degree of resistance and ensuring successful transitions and positive outcomes are discussed. Communication is essential during organizational change, and an entire chapter is devoted to this topic. SECTION IV. OUTCOMES AND DOCUMENTATION Documentation is a powerful tool to advocate for your clients’ needs and for your skilled services. Well-written documentation can show that you deliver prompt, quality, client-centered care with measurable outcomes using evidence-based practice. Section IV, “Outcomes and Documentation,” contains 9 chapters that examine best practices for care delivery, measuring outcomes, and documentation. As the health care systems in the United States shift from fee-for-service care, documentation of quality care will be essential to receiving compensation. Section IV examines the current third-party payer systems and looks at an emerging area of health care delivery: telehealth. SECTION V. INTERPROFESSIONAL PRACTICE AND TEAMS Occupational therapy practitioners have a distinct value in the care of populations across the lifespan. The occupational therapy practitioner’s role may vary based on the needs of the client population, the type of setting, or the access to resources; however, a common denominator in effective care is the collaboration of members of the interprofessional team to achieve quality care and desirable client outcomes. The ability to contribute to the effective care of a client is best supported when working with other disciplines to collectively achieve the goals that are in the client’s best interest. Collaboration with team members who together work closely with the client and family can not only lead to effective outcomes but also improve the quality of the relationships between the various disciplines on the team (World Health Organization, 2012). Section V, “Interprofessional Practice and Teams,” contains 3 chapters that examine the distinct role of occupational therapy practitioners in interprofessional teams and also optimal action steps and behaviors to be an effective team member while working with various disciplines. An occupational therapy practitioner can be a part of many dynamic relationships while working as a member of an interprofessional team. In fact, the practitioner must learn to juggle many roles: working as a practitioner, working as a team member, and for some, working as a supervisor of these dynamic teams. Active interprofessional collaboration among all health disciplines on the same team is vital for the coordination and delivery of client-centered health care. SECTION VI. SUPERVISION Today’s students are tomorrow’s leaders; being a leader and manager today means having the privilege and responsibility to train and mentor junior practitioners and students. Section VI, “Supervision,” contains 8 chapters that examine the cycle of recruiting, hiring, mentoring, and managing junior practitioners. It looks at mentoring as more than a positive role model relationship; instead, it views mentoring as a relationship that promotes professionalism, motivates, and provides constructive feedback for both practitioners. This section also looks at the supervisory roles between occupational therapy practitioners and students in fieldwork. SECTION VII. COMMUNICATION Although it has been said that “words connote reality” (Coster, 2008, p. 744), one must learn to use them skillfully Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Introduction because, in words often attributed to George Bernard Shaw, “The greatest problem in communication is the illusion that it has been accomplished.” This means two things: One, we cannot assume that our beliefs are known by an audience, and two, we cannot assume that our beliefs are shared by the audience. Occupational therapy practitioners and students become accomplished communicators only when they can effectively communicate that occupation is essential to individuals’ and society’s health and well-being (Jacobs, 2012). Section VII, “Communication,” contains 4 chapters that examine common communication challenges and different mediums for communication. As a manager you will have to communicate with people from different cultures and generations, and each situation may bring its own issues and surprises; this section addresses many of those. Communication goes beyond sharing information in traditional ways. With today’s social media platforms, the virtual environment is open for information sharing, and as practitioners, we have an opportunity to share powerful stories and vital information. Effective communication is also essential for proposing grants and writing successful proposals. We are health communicators, and the words we use are important as we “share health-related information with the goal of influencing, engaging and supporting individuals, communities, health professionals, special groups, policy makers and the public to champion, introduce, adopt, or sustain a behavior, practice or policy that will ultimately improve health outcomes” (Schiavo, 2007, p. 7). SECTION VIII. FINANCE AND BUDGETING Financial considerations are an important aspect of any endeavor. It is necessary to know where your business is in relation to expenses and profitability. Although many occupational therapy managers see themselves as occupational therapy practitioners, not business people, understanding business practices is crucial to the success or failure of occupational therapy practice itself. Section VIII, “Finance and Budgeting,” contains 6 chapter that examine how general business practices and strategies are applied to occupational therapy practice and management. The chapters in this section are interrelated and important to the financial health of a clinic or program. Readers are not asked to be accountants, but managers must fully understand the business fundamentals presented. As health care costs continue to rise, medical care is becoming increasingly difficult to pay for. With the Patient Protection and Affordable Care Act of 2010 (P. L. 111–148) and its requirements, some individuals and families are paying higher deductibles and are concerned about how to pay for care. Insurance policies with lower deductibles have higher premium costs, making coverage out of reach for some. However, increasing the focus on quality, patient satisfaction, and cost effectiveness creates opportunities to demonstrate the value of occupational therapy. xxv SECTION IX. PROFESSIONAL STANDARDS Professional standards are the backbone of a health profession and have elevated the discipline of occupational therapy to what it is today. Professional standards provide a framework for consistency of practice, safety for the consumer, and ethical practices. Today, licensing boards enforce the practice act and the laws; they also litigate against those refusing to participate within their scope of practice or those who conceal any unethical, false, fraudulent, or deceptive activity. Section IX, “Professional Standards,” contains 3 chapters that examine the historical scene surrounding occupational therapy standards and the continued reasons for them. The section addresses some major accrediting organizations and related educational requirements. Occupational therapy is not a job; it is a profession. The cost of education is increasing, and the cost to be a member of a professional organization, as well as the cost of credentialing and licensure, can be expensive. Continuing competency, accrediting agencies, and even the development of professional standards add to the cost of being a professional. Students often ask: Why are professional regulations so important? Why is it so important to belong to a professional organization? Why is it so time-consuming to be a professional? The answer is, we as occupational therapy practitioners are the only profession that enables a person to carry out the activities and roles they need, want, or are expected to do in their daily life. We enable people to carry on with their occupational performance. SECTION X. ETHICAL AND LEGAL CONSIDERATIONS Section X, “Ethical and Legal Considerations,” contains 10 chapters. Managing occupational therapy services and personnel is a complex enterprise marked by market pressures to “do more with less” in a pluralistic society. Because of the complexity of the health care system, occupational therapy managers and practitioners alike may find it difficult to adhere to the ethics standards that traditionally have defined and molded clinical practice. Merely being aware of AOTA’s Occupational Therapy Code of Ethics (2015) (2015; hereinafter, the “Code”) will not result in the resolution of many ethical conflicts encountered in practice. Using the Code in conjunction with licensure board regulations, standards of practice, and related laws may optimize the chances of adopting and promoting ethical behaviors, but managers must cultivate professional behaviors that support ethical decision-making. Most health care professionals practice ethics every day and may not even realize they are applying the concepts of right and wrong to choices in their daily lives. However, readers should recognize that the study of ethics is systematic in nature and is grounded in philosophical principles and theory. To apply ethical reasoning in management, practitioners must be able to differentiate among ethics, morality, and the Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] xxvi The Occupational Therapy Manager law. Given the complexity and diversity of the environments in which occupational therapy services are provided, ethical reasoning must be applied appropriately, and practitioners must refrain from making decisions solely based on value-­ laden judgments. Acting legally is a minimum standard of behavior, and while managers must be familiar with and abide by the law, professional ethics holds one to a higher standard. Understanding the language of ethics as well as the foundational philosophy undergirding ethical reasoning is an antecedent to acting ethically. SECTION XI. MANAGING YOUR CAREER Section XI, “Managing Your Career,”contains 6 chapters that examine concepts and information relevant to managing a service or organization, leading people, driving performance improvement, and promoting the occupational therapy profession. A properly managed department can achieve high-value outcomes and satisfaction among staff and clients. Similarly, a properly managed career can achieve high-value outcomes for the individual practitioner on both a personal and professional level. Managing one’s own career often means having the responsibility and freedom to direct your own professional path across a continuously evolving business and health care landscape. SECTION XII. PUBLIC POLICY Public policy affects you in everyday life in more ways than you are aware of. It touches the systems and institutions that you rely on in your personal life, and it overtly influences and shapes the health care, education, or other service system you work in or around. The text concludes with Section XII, “Public Policy,” which contains 4 chapters that examine public policy affecting health care systems and payment issues from the federal and state levels. This section goes beyond explaining why an interest in public policy is important and articulates how you can be an advocate and agent of change. It is your responsibility as occupational therapy practitioners and students to help create the future we envision for our beloved profession. FUTURE DIRECTIONS According to U.S. News and World Report (2019), occupational therapy ranks number 13 in the 100 Best Jobs report. A job can be considered an activity through which an individual can earn money. A career is the pursuit of a lifelong ambition or the general course of progression toward lifelong goals. When managing one’s own career, individuals are considered to be active players or main agents in managing and shaping their career trajectories. Emerging practices and opportunities created by changes in health care and reimbursement models provide practitioners with a greater scope to construct their career paths. These newly constructed career paths are mainly derived from individual choices and preferences. “People are becoming the masters of their own destiny, and thus the managers of their careers” (Baruch, 2006, p. 127). The transformation of the occupational therapy profession during the past 100 years and the increase in practitioner autonomy lead us toward becoming more responsible for the destiny of our careers and the profession. Change also brings opportunities for adding value. As change brings about new values for collaborative work environments, it requires team members to adopt newer and better evidence-based practices. Change depends on change agents. Developing the confidence to bring about positive change affects occupational therapy practice and client outcomes. We hope you find that the 6th edition of The Occupational Therapy Manager provides you with tools to confidently and competently be an agent of change. REFERENCES American Occupational Therapy Association. (2015). Occupational therapy code of ethics (2015). American Journal of Occupational Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014/ajot.2015 .696S03 Baruch, Y. (2006). Career development in organizations and beyond: Balancing traditional and contemporary viewpoints. Human Resource Management Review, 16(2), 125–138. https:// doi.org/10.1016/j.hrmr.2006.03.002 Coster, W. J. (2008). Embracing ambiguity: Facing the challenge of measurement (Eleanor Clarke Slagle Lecture). American Journal of Occupational Therapy, 62, 743–752. http://doi.org/10.5014 /ajot.62.6.743 Doorewaard, H. & Benschop, Y. (2002). HRM and organizational change: An emotional endeavor. Journal of Organizational Change Management, 16(3), 272–286. http://doi.org/10.1108 /09534810310475523 Jacobs, K. (2012). PromOTing occupational therapy: Words, images, and actions [Eleanor Clarke Slagle Lecture]. American Journal of Occupational Therapy, 66, 652–671. http://doi.org/10.5014 /ajot.2012.666001 Patient Protection and Affordable Care Act of 2010, Pub. L. 111–148, §3502, 124 Stat. 1999, 124 (2010). Schiavo, R. (2007). Health communication: From theory to practice. San Francisco: Jossey-Bass. U.S. News and World Report. (2019). The 100 best jobs of 2018. Retrieved from https://money.usnews.com/careers/best-jobs /rankings/the-100-best-jobs World Health Organization. (2012). Being an effective team player. Geneva: WHO. Retrieved from http://www.who.int/patientsafety /education/curriculum/who_mc_topic-4.pdf Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] SECTION I. Foundations of Occupational Therapy Leadership and Management Edited by Karen Jacobs, EdD, OT, OTR, CPE, FAOTA 1 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Theories of Leadership 1 Virginia “Ginny” Stoffel, PhD, OT, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ Define leadership, List Spears’s (2000) 10 characteristics associated with effective servant leaders, Describe transformational leadership, Compare transactional leadership to transformational leadership, and Discuss features of AOTA’s Emerging Leadership Development Program and Middle Manager and Executive Leadership Institute Programs. KEY TERMS AND CONCEPTS • Call to serve • Core values • Leadership coherence • Leadership sustainability • Servant leadership • Transactional leadership OVERVIEW T his chapter addresses readers as current and future lead­ ers in the profession of occupational therapy. Rooted in a contemporary perspective that to be an effective occu­ pational therapy practitioner one must be aware of and engage in leadership opportunities that pave the journey toward the American Occupational Therapy Association’s (AOTA; 2017b) Vision 2025, this chapter encourages readers to personally ex­ plore values that underlie leadership activation across their professional careers. Leadership theories, conceptual models, and important constructs are illuminated so that as occupational therapy practitioners develop their leadership capacities, they can appreciate the complexity of what it means to lead and how to explore and expand their leadership capacity, the capac­ ity of those they lead, and the organizations they influence and to which they are accountable. Whether the efforts are to shape the environment (e.g., by leading student activists toward making beaches accessible to persons with mobility disabilities) or to shape policies (e.g., by calling for inclu­ sion of occupational therapy practitioners as members of the • Transformational leadership • Vision 2025 behavioral health workforce staffing certified community be­ havioral health clinics), understanding theories about lead­ ers, leadership development, and leading effectively can help leaders mindfully engage in leadership as a process of influ­ ence toward a goal that produces the greatest common good (Dickmann & Stanford-Blair, 2009). ESSENTIAL CONSIDERATIONS What does it mean to be a leader? What calls people into tak­ ing on and assuming leadership roles? What are the character­ istics of an effective leader? How does a leader act to influence others? What role does reflection play in leadership develop­ ment? How do leaders build on their core values to defining their purpose or mission and outcomes? How can a leader cre­ ate a path of sustainability? This section explores these ques­ tions while examining several leadership theories and models, and readers are encouraged to apply these questions in a per­ sonal manner (e.g., What does it mean for me to be a leader? What calls me toward taking on and assuming a leadership role?) as they move through this chapter. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.001 3 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 4 SECTION I. Foundations of Occupational Therapy Leadership and Management Servant Leadership Servant leadership, a term first coined by AT&T executive and management consultant Robert K. Greenleaf (1977/2002), is a theory of leadership that focuses on the leader and offers a per­ spective of the motivation and character of the leader. The servant–leader is servant first. It begins with the natural feeling that one wants to serve. Then conscious choice brings one to aspire to lead. The best test is this: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants? And, what is the effect on the least privileged in society? Will they benefit or at least not be further deprived? (Greenleaf, 1977/2002, p. 27) The leader’s inclination to serve is the mark of the servant leader. Readers might pay attention to what they perceive as a call to serve, especially when that call is matched with any of the distinct values of occupational therapy (AOTA, 2015). The call to serve may happen without conscious deliberate thought but manifests as an inner drive to intervene consis­ tent with one’s values and ethics as an occupational therapy practitioner. Once the lived experience of serving and leading occurs, a more conscious decision might follow (e.g., “I did that. It made a difference. I wonder if there is more I can do to contribute”). Stoffel’s (2013) AOTA Inaugural Presidential Address, “From Heartfelt Leadership to Compassionate Care,” high­ lights envisioning every AOTA member as a leader, which, in turn, expands the commitment of the organization to con­ tinually building leadership capacity for all members and ac­ tively building the organization’s capacity to use and depend on its members for effective leadership. When servant lead­ ership is implemented in this manner, sustainable leadership becomes a reality. Spears (2000) emphasized 10 characteristics associated with effective servant leaders: 1. 2. 3. 4. 5. 6. 7. Listening (for deep understanding combined with reflection) Empathy Healing Awareness (general and heightened self-awareness) Persuasion (effective at building consensus) Conceptualization (keeping in mind the big picture) Foresight (combines an understanding of the past, reali­ ties of the present, and potential future consequences) 8. Stewardship (full commitment to serving others) 9. Commitment to the growth of people (being sure that resources are expended as investments in those being served, who then join in serving) 10. Building community (within the organization being served). Readers are encouraged to reflect on these characteristics and examine their own experiences for evidence of these, as well as finding exemplars in leaders with whom they observe and work. Moreover, readers are encouraged to build a clear picture of how these characteristics shape how servant lead­ ers work with others, build their own capacity as well as that of others, and facilitate a shared vision toward which to focus their collective efforts. Reflection is a disciplined habit for servant leaders because it enhances self-awareness as well as awareness of others and creates an optimum environment for careful decision-making and goal-setting in a manner that integrates these 10 characteristics. Servant leaders work with others in a collaborative style that downplays hierarchical structures and emphasizes that the leaders listen carefully, get to know the strengths and tal­ ents of others, and build their capacity so that they can be­ come autonomous. Philosophically, servant leaders embrace the values of altruism and humanism, creating a culture of mutual respect and shared power. Servant leaders share in­ fluence and focus on capacity-building (self, others, organiza­ tion). Liden et al.’s (2008) 28-item Servant Leadership Ques­ tionnaire consists of 7 distinct dimensions, similar to Spears’s (2000) characteristics: 1. 2. 3. 4. 5. 6. 7. Conceptualizing Emotional healing Putting followers first Helping followers grow and succeed Behaving ethically Empowering Creating value for community. Linden et al.’s research noted that servant leadership has the greatest impact when the followers want to be involved in growth and are open to this style of leadership. Leadership Coherence On the basis of stories collected from 36 exemplary global leaders, Stanford-Blair and Dickmann (2005a, 2005b) devel­ oped a model of leadership coherence. They asked 3 main questions when eliciting their leadership development stories: 1. How were you formed as a leader? 2. How do you perform as a leader? 3. How do you sustain your leadership over time and adversity? Stanford-Blair and Dickmann discovered that each leader was guided by unshakeable core values that influenced how they led. Their inner values were coherent with their leader­ ship disposition and how they connected with and influenced others. The core values themselves were not necessarily the same across the leader participants; rather, when each re­ flected on the questions, the stories reflected each leader’s per­ sonally held core values. What also emerged was the notion that their leadership influence and behaviors tended to reflect those core values, hence the “leadership coherence” perspec­ tive: that leaders enacted their values, and did so across time, with a pattern of self-care habits. This pattern of self-care habits was also “observed as a reciprocal relationship in that what the leaders did to Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 1. Theories of Leadership sustain their leadership reinforced their performance, and performance, in turn, reinforced core values nested at the heart of the leaders’ formative experience” (Stanford-Blair & Dickmann, 2005a, p. 65). Therefore, readers will find a values exercise in the “In-Class Assignments and Reflec­ tive Exercises” section to discern 3 to 4 (no more!) core values that will be reflected in their leadership experiences across time. Leadership Sustainability Leadership sustainability themes were extracted from Stanford-Blair and Dickmann’s (2005b) study. Sustainabil­ ity was considered an element of leadership coherence as a means of continually building capacity at the organizational level as well as expanding leadership influence to achieve organizational goals and building a legacy. The practices they found endorsed by the 36 exemplary global leaders are ■ ■ ■ ■ ■ ■ ■ Staying physically fit; Managing emotions to one’s mental and physical advantage; Valuing counsel from family, friends, and colleagues; Creating space for maintaining clarity and perspective; Gaining satisfaction on the challenges and results associ­ ated with one’s commitments; Seeking intellectual stimulation; and Welcoming inspiration through connection to a higher purpose. As you read through this list, reflect on your own habits and how they contribute to your fitness as a leader. Think about strategies you could use to incorporate more of these self-sus­ taining behaviors into your routines. Observe and ask role models of leadership excellence around you to determine how and what their self-care strategies are and how they affect leadership effectiveness across time and adversity. 5 well beyond what might be expected. Bass stated that a trans­ formational leader ■ Is perceived by followers as a strong role model whom ■ ■ ■ others want to emulate, a leader who is deeply respected and trusted and who provides followers with vision and a sense of mission; Inspires a team spirit in which people are motivated to be part of the shared vision and to achieve high expectations; Offers intellectual stimulation by encouraging creativity, innovation, and an openness to challenging one’s own be­ liefs and values; and Provides followers with individualized consideration through listening carefully and providing supportive feed­ back, helping followers grow through the process. Transformational leaders share many of the characteris­ tics of servant leaders and are offered here as another source of information that readers can use to examine their own leadership development process. Whereas transformational leaders might not always be servant leaders, servant leaders are likely to be transformational leaders, given how they work. Taken together, they offer rich information to emerg­ ing leaders in occupational therapy. Review Questions 1. What role do values play in the development of leaders, and how does leadership coherence shape the ways that leaders behave? 2. How does the servant leader contrast with leaders who emphasize power and control? 3. What are the kinds of habits that lead to leadership sustainability? Other Theories PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Several other leadership theories commonly referenced in the health care leadership and management literature will be briefly explored, including transactional and transfor­ mational leadership (Ledlow & Coppola, 2014; Northouse, 2016). Transactional leadership is often described as a prag­ matic give-and-take process, such as the exchange that oc­ curs when a high-performing employee is rewarded with a promotion, when the organization is set up to reward those who are viewed as high performers. In general, transactional leaders are viewed as able to deliver expected outcomes based on their brokering skills. In contrast, transformational leadership is a process of having the leader connect with follow­ ers in a manner that heightens motivation by attending to their needs and engaging them as team members. Transac­ tional leadership was explained by Burns (1978) as a contrast to transformational leadership. Bass (1985) built on Burns’s (1978) work to describe how transformational leaders engage others to achieve outcomes Beginning with AOTA’s concerted efforts as it planned for 2017 and its 100th anniversary, AOTA’s (2007) Centennial Vision called for occupational therapy practitioners to be “powerful.” In 2008, the AOTA Representative Assembly (RA) voted to approve a proposal that supported the devel­ opment of leadership development programs, consistent with then–AOTA President Penny Moyers’s (2007) call for creat­ ing a legacy of leadership. Between 2009 and 2017, nearly 200 occupational therapy practitioners and occupational therapy assistants partici­ pated in the AOTA Emerging Leadership Development Pro­ gram or the AOTA Middle Manager and Executive Leader­ ship Institute Programs, in addition to targeted leadership development programs for academic leaders, scientists, state association presidents, and RA members. Graduates of the first 2 named programs have gone on to fill significant lead­ ership roles within AOTA, state associations, and other inter­ professional organizations. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 6 SECTION I. Foundations of Occupational Therapy Leadership and Management In addition, consistent with the development of the clinical doctorate (Accreditation Council for Occupational Therapy Education, 2012; 2018; Case-Smith et al., 2014), leadership ex­ pectations of occupational therapists trained at the doctoral level were expanded to include advocacy, care coordination, and leadership of interprofessional teams and systems to pro­ vide high-quality, evidence-informed, and cost-effective pro­ grams with high satisfaction from those they serve. Hence, the emphasis on leadership development begins in professional entry programs for occupational therapists and occupational therapy assistants and continues throughout one’s profes­ sional career as new theories and science about leadership are discovered and applied to occupational therapy, health care, education, and community health. Given the increased emphasis on exploring oneself as a leader who will influence others (those one serves, those one works with, the public, and one’s communities), the AOTA Vision 2025 can be used as a focus for leadership efforts and to examine the possibilities for future leadership initiatives led by occupational therapy practitioners: “Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effec­ tive solutions that facilitate participation in everyday living” (AOTA, 2017a, p. 1). In addition to this statement, AOTA developed several guideposts to ensure that the core tenets of Vision 2025 were clearly communicated: ■ Accessible: Occupational therapy provides culturally responsive and customized services. ■ Collaborative: Occupational therapy excels in working ■ ■ with clients and within systems to produce effective outcomes. Effective: Occupational therapy is evidence based, client centered, and cost-effective. Leaders: Occupational therapy is influential in changing policies, environments, and complex systems. (AOTA, 2017b, p. 1) When the AOTA Centennial Vision was articulated, dis­ seminated, and used as the focus of national, state, and local occupational therapy leadership efforts, the key words and concepts embedded in the vision were carefully scrutinized, shared, developed, and expanded over time to meet the changing priorities. To align efforts to meet the Centennial Vision, AOTA created the Centennial Commission, chaired by the AOTA vice president. The chairs of all the organiza­ tional commissions or official bodies were represented at a quarterly meeting during which leaders shared their current and planned activities and framed their focus on one or more parts of the Centennial Vision. For example, the development of practice tools that were evidence informed was a priority of the Special Interest Section Council (SISC), aligned with the emphasis on “science-driven” and “evidence-based” terms in the Centennial Vision. Given the changing environment for occupational therapy services in health care, social services, public health, educa­ tion, and community programs, innovative leaders will likely implement quality improvement strategies to boost outcomes by emphasizing health and wellness alongside traditional approaches used in rehabilitation settings. In addition, oc­ cupational therapy entrepreneurs will look for opportunities to establish community-based programs directed to specific populations and the well-being of the community overall. A recent example of this is the work of Susan Bazyk, pro­ fessor of occupational therapy at Cleveland State University. She engaged in efforts to train school-based occupational therapy practitioners across Ohio to work as change agents in their school districts to influence mental health promo­ tion strategies in a public health manner, not only meeting the needs of students identified as requiring individualized education plans but also addressing students at risk for men­ tal health issues, as well as promoting mental health for all students (Bazyk et al., 2015). Review Questions 1. Reflect on Vision 2025 and identify 3 areas that you could focus your attention on that would help achieve what is envisioned in this statement. 2. How do the Vision 2025 guideposts provide important clarification on aspects that need to be addressed so the profession meets goals for diversity, inclusion, and collaboration? 3. Talk with your peers, occupational therapy practitioners, and others in your community to identify several strate­ gies for engaging leadership at the state level to increase membership engagement and leadership that will facili­ tate leadership development at the local level. What would activate you to be a leader at the local or state levels? SUMMARY This chapter was intended to provide readers with information about leadership and leadership development, theories, and vision, all designed to build their leadership capacity. The re­ view questions were meant to highlight important content as well as encourage readers to connect the concepts with their own development and observations of leaders around them. Leadership in contemporary occupational therapy prac­ tice is not only important for those who pursue formal orga­ nizational leadership roles, as was seen in the case example but also to synthesize leadership within practice settings, promote collaborative interprofessional practice, influence policies at the population and community levels, and ulti­ mately influence the state of health, well-being, and quality of life for all persons, populations, and communities, resonant with AOTA’s Vision 2025. ❖ LEARNING ACTIVITIES 1. Using Appendix 1.A., “Values Card Sort Activity,” copy or print the list of values, and cut them into “cards.” Carefully read through the entire list of values, includ­ ing the definitions. Read them a 2nd time, and identify Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 1. Theories of Leadership 7 CASE EXAMPLE 1.1. Ginny Stoffel’s Leadership Journey As a lifelong learner and an active leader across my entire career from the time I was an occupational therapy student more than 40 years ago, I offer my own leadership development reflections as the “case” to ponder in this chapter. It is fitting that one of my earliest occupational therapy mentors was Sister Genevieve Cummings, a faculty member and department chair at the College of St. Catherine, who was serving in the AOTA RA and the AOTA Executive Board around the time I was a student. Sister’s leadership style was examined by Dillon (2001) as an exemplar of an authentic and effective leader who embodied servant leadership in her demeanor and actions, and I must admit the servant leader practices were a good fit for me as well. In addition, I must also give sincere thanks for Sally Ryan, another faculty member at St. Catherine’s, who was honored in 2016 as one of “occupational therapy’s 100 influential people” (www.otcentennial.org; AOTA, 2017a) for her role in education, authoring a primary text for occupational therapy assistant students, and for her leadership, serving as the first occupational therapy assistant on the AOTA Executive Board and the first occupational therapy assistant to receive the Roster of Honor award to high-achieving occupational therapy assistants. These women served not only as my mentors but also as role models and champions for helping me connect with occupational therapy leaders across the United States during my 2 years as a student and actively for my first decade as a practitioner. With their encouragement, I first pursued opportunities to participate in the Commission on Education (as a student, then a fieldwork practitioner), which allowed me to participate in shaping educational standards and practices. Later I served on the Commission on Practice, during which the first version of the Occupational Therapy Practice Framework was developed (AOTA, 2002); the SISC as the Mental Health chair and later the SISC chair; the RA, where I helped shape professional policies; the Commission on Continuing Competence and Professional Development, helping to develop board certifications in gerontology and mental health; and the Board of Directors twice, serving a dual role as AOTA’s first alternate representative to the World Federation of Occupational Therapists, and on the AOTA RA, representing members who reside outside of the United States. At a more local level, beginning in the early 1980s, I served on the Wiscouncil Steering Committee (Wisconsin Occupational Therapy Education Council) and the Wisconsin Occupational Therapy Association Board. I sought out active board or leadership positions in Transitional Living Services, a community-based organization providing housing, recovery programs, and employment for adults with psychiatric disabilities, and served on committees and chaired the board for Mental Health America of Wisconsin (2001–2012). When I pursued a doctorate, I was drawn to Cardinal Stritch University’s PhD in Leadership for the Advancement of Learning and Service, being able to add new knowledge, lots of reflection, and carried out my dissertation research in a mental health clubhouse community where shared leadership of members and staff provided a rich foundation to explore its impact on mental health recovery. While writing this chapter, I especially enjoyed rereading Dillon’s (2001) historical work on Sister Genevieve Cummings and was amazed at how much I could relate to her ways of leading and developing habits of the mind and spirit as a leader. I find myself drawn toward continually expanding my learning from others, while at the same time focusing on the needs of others in an authentic, holistic, and inclusive manner, like Sister did. I get feedback from others about my open and accessible style, and Sister was seen to openly share her lived experiences and wisdom; during troubling times, we both find a calm demeanor helps to facilitate reasoned action. One of Dillon’s final quotes illustrates Sister Genevieve’s inclusive style: “In addition, when collaboratively developing a vision for an organization or group and leading in a manner that is caring and inclusive, the leader indicates that each constituent plays an important role in achieving group success” (pp. 447–448). I am hopeful that should a retrospective analysis of my years as AOTA vice president and president occur, we will see how the organization successfully activated leadership and leadership development (remember my early mantra, “Every member a leader,” which by 2016 was “Every member a leader, a member for life”) as priorities that served society, the profession, and AOTA. In Fall 2017, as cofacilitator of the AOTA Emerging Leaders Development Institute, I joined the participants in building a personal mission statement after a deep period of reflection, values clarification, and sharing. Here is what I developed as that personal mission statement: “My mission is to lead through engagement (doing with) by offering mindfulness, reflection, and cultivation of trust to support the growth of others” (dated September 26, 2017). At this point in my career, there is nothing I would love more than to continue to cultivate genuine and authentic leaders in occupational therapy, in the United States and globally. Review Questions 1. 2. 3. What influences did Sister Genevieve Cummings and Sally Ryan have on Ginny’s early leadership experiences in AOTA and occupational therapy? What characteristics of a servant leader do you see in Ginny’s case reflections and in her 2013 Inaugural Presidential Address, “From Heartfelt Leadership to Compassionate Care”? How do you view the various leadership roles within AOTA, occupational therapy state associations, and other organizations as they influenced Ginny’s leadership development over time? how you would code each value for you (always valued, often valued, sometimes valued, seldom valued, least valued). Mark the sheet or place into card piles until you have coded all values, with only 3 cards in the “always valued” pile. 2. Ref lect on your core values and identify how you came to understand these as your core values. Share them with a partner, and tell a story about how these came to be your core values and how they have been tested over time. 3. Reflect on how these core values might influence the kind of leader you hope to be and how they will guide your leadership development and the skills and capacities you are working on. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 8 SECTION I. Foundations of Occupational Therapy Leadership and Management 4. Based on an understanding of your core values, try to develop a purpose or mission statement reflecting the goals you hope to achieve as a leader. See the examples shared in the chapter. Read how participants in AOTA’s Emerging Leader Develop­ ment Program experienced this process (Amanat et al., 2016). 5. Spend time reflecting on AOTA’s Vision 2025. Identify the possibilities for leadership influence where you live, study, and practice occupational therapy to enact this vi­ sion. Create a leadership mission statement for the por­ tion of Vision 2025 that you hope to achieve in the next year. Share your mission with another occupational ther­ apy student or practitioner. Ask for this person’s support and engagement in helping you develop your leadership capacity to actualize your goal. ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ B.7.1. Ethical Decision Making ■ B.7.2. Professional Engagement. REFERENCES Accreditation Council for Occupational Therapy Education. (2012). 2011 Accreditation Council for Occupational Therapy Education (ACOTE) standards. American Journal of Occupational Therapy, 66, S6–S74. https://doi.org/10.5014/ajot.2012.66S6 Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org /10.5014/ajot.2018.72S217 Amanat, Y., Lingelbach, S., & Schoen, T. (2016, July 25). OT Per­ spectives—Core values: A leader’s guiding principles. OT Practice, 24–25. American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609–639. https://doi .org/10.5014/ajot.56.6.609 American Occupational Therapy Association. (2007). AOTA’s Centennial Vision and executive summary. American Journal of Occupational Therapy, 61, 613–614. https://doi.org/10.5014 /ajot.61.6.613 American Occupational Therapy Association. (2015, May 22). Articulating the distinct value of occupational therapy. Retrieved from https://www.aota.org/Publications-News/AOTANews/2015 /distinct-value-of-occupational-therapy.aspx American Occupational Therapy Association. (2017a, December 18). The AOTA centennial year that was—and those who made it all possible. OT Practice, 22–25. American Occupational Therapy Association. (2017b). Vision 2025. American Journal of Occupational Therapy, 71, 7103420010. https://doi.org/10.5014/ajot.2017.713002 Bass, B. M. (1985). Leadership performance beyond expectations. New York: Free Press. Bazyk, S., Demirjian, L., LaGuardia, T., Thompson-Repas, K., Con­ way, C., & Michaud, P. (2015). Building capacity of occupational therapy practitioners to address the mental health needs of chil­ dren and youth: A mixed-methods study of knowledge transla­ tion. American Journal of Occupational Therapy, 69, 6906180060. https://doi.org/10.5014/ajot.2015.019182 Burns, J. M. (1978). Leadership: Transformative leadership, transactional leadership. New York: Harper & Row. Case-Smith, J., Page, S. J., Darragh, A., Rybski, M., & Cleary, D. (2014). The Issue Is—The professional occupational therapy doc­ toral degree: Why do it? American Journal of Occupational Therapy, 68, e55–e60. https://doi.org/10.5014/ajot.2014.008805 Dickmann, M. H., & Stanford-Blair, N. (2009). Mindful leadership: A brain-based framework (2nd ed.). Thousand Oaks, CA: Corwin Press. Dillon, T. H. (2001). Authenticity in occupational therapy lead­ ership: A case study of a servant leader. American Journal of Occupational Therapy, 55, 441–448. https://doi.org/10.5014 /ajot.55.4.441 Greenleaf, R. K. (2002). Servant–leadership: A journey into the nature of legitimate power and greatness. Mahwah, NJ: Paulist Press. (Original work published 1977) Ledlow, G. R., & Coppola, M. N. (2014). Leadership for health professionals: Theory, skills and applications. Burlington, MA: Jones & Bartlett Learning. Liden, R. C., Wayne, S. J., Zhao, H., & Henderson, D. (2008). Ser­ vant leadership: Development of a multidimensional measure and multi-level assessment. Leadership Quarterly, 19, 161–177. https://doi.org/10.1016/j.leaqua.2008.01.006 Moyers, P. A. (2007). A legacy of leadership: Achieving our Centennial Vision. American Journal of Occupational Therapy, 61, 622–628. https://doi.org/10.5014/ajot.61.6.622 Northouse, P. G. (2016). Leadership theory and practice (7th ed.). Thousand Oaks, CA: Sage. Spears, L. C. (2000). Character and servant leadership: Ten charac­ teristics of effective, caring leaders. Concepts and Connections: Newsletter of the National Clearinghouse for Leadership Programs, 8(3). Stanford-Blair, N., & Dickmann, M. H. (2005a). Leadership coher­ ence: An emerging model from interviews with leaders around the globe. In N. S. Huber & M. C. Walder (Eds.), Emergent models of global leadership (pp. 50–66). College Park, MD: International Leadership Association. Stanford-Blair, N., & Dickmann, M. H. (2005b). Leading coherently: Reflections from leaders around the world. Thousand Oaks, CA: Sage. Stoffel, V. C. (2013). From heartfelt leadership to compassionate care. American Journal of Occupational Therapy, 67, 633–640. https:// doi.org/10.5014/ajot.2013.676001 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 9 CHAPTER 1. Theories of Leadership APPENDIX 1.1. VALUES CARD SORT ACTIVITY Always Always Always Always Valued Valued Valued Valued Values Cards Values Cards ValuesCards Cards Values Sometimes Sometimes Sometimes Sometimes Often Valued Often Valued OftenValued Valued Often Valued Valued Valued Valued Seldom Seldom Seldom Seldom Valued Valued Valued Valued Least Valued Least Valued LeastValued Valued Least (Continued) Source. Adapted from “Personal Values Card Sort,” 2001, by W. R. Miller, J. C’de Baca, D. B. Matthews, & P. L. Wilbourne. In the public domain. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 10 SECTION I. Foundations of Occupational Therapy Leadership and Management APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.) Challenge Rationality Testing your limits physically Emotionally detached, clear logical thinking Tradition Power Consideration for the way things have customarily been done The ability to influence the behavior of myself and others Competence Self-Control Being good at what I do, capable, effective Restraint, able to discipline self (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 11 CHAPTER 1. Theories of Leadership APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.) Stability Perseverance Dependability, able to predict experience Staying with tasks through completion Respectful Honesty Regarding others with honor and consideration Expressing only the truth Personal Growth Communication Committed to a process of ever developing selfawareness and skills Open exchange of views (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 12 SECTION I. Foundations of Occupational Therapy Leadership and Management APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.) Helping Forgiveness Reaching out out to to meet meet Reaching other’s needs needs other’s Capable of of pardoning pardoning and and Capable moving on on moving Family Inner Harmony Attending to to and and enjoying enjoying Attending time with with loved loved ones ones time Seeking inner inner peace peace and and Seeking integration integration Peace Diplomacy End of of war, war, nonviolent nonviolent End conflict resolution resolution conflict Searching for for common common ground ground Searching to resolve resolve conflict conflict to (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 13 CHAPTER 1. Theories of Leadership APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.) Play Courageous Doing just for fun, spontaneity Standing up for what you believe in, even when risky Community Appearance Close involvement with neighbors Taking care of looks, dressing well, keeping in shape Consensus Adventure Forming decisions everyone can support Taking risks, challenging yourself (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 14 SECTION I. Foundations of Occupational Therapy Leadership and Management APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.) Competition Aesthetic “Beating” others, others, “Beating” coming in in first first coming Respect for for beauty beauty and and Respect artistry artistry Safety Intellectual Status Security, free free from from Security, risk and and worry worry risk Being seen seen as as aa Being knowledgeable expert expert knowledgeable Prosperity Advancement Able to to afford afford things things you you Able want, well well off off want, Wanting to to move move up, up, Wanting get ahead ahead get (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 15 CHAPTER 1. Theories of Leadership APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.) Integrity Integrity Your Youractions actionsmatch match your yourbeliefs beliefs Spiritual Growth Connection higher Connection to a higher purpose, presence purpose, divine presence Intimacy Intimacy Neatness Solidand anddeep deepemotional emotional Solid relationship relationship Having things things clean Having clean and in in order order and Friendship Friendship Self-Esteem Self-Esteem Ongoing close relationships Ongoing close relationships Accepting and Accepting and respecting yourself respecting yourself (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 16 SECTION I. Foundations of Occupational Therapy Leadership and Management APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.) Creativity Pleasure Open Open to to discovery discovery of of new new ways, ways, innovative innovative Seeking Seeking enjoyment enjoyment and and delight delight Teamwork Health Collaborating with with others others to to Collaborating reach goals goals reach Tending to to physical physical and and Tending mental well-being well-being mental Tolerance Respecting Respecting those those different different from from you you Achievement Visible Visible evidence evidence of of successfully successfully completed completed endeavors endeavors (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 17 CHAPTER 1. Theories of Leadership APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.) Fairness Authority Treating everyone everyone equally, equally, Treating with respect respect with Steering the the process, process, having having Steering power to to direct direct events events power Knowledge Belonging Continuous learning, looking for intellectual intellectual stimulation stimulation for Being accepted accepted and and Being liked by by others others liked Ecology Recognition Taking care care of of the the Earth Earth Taking Having others others notice notice Having good work work good (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 18 SECTION I. Foundations of Occupational Therapy Leadership and Management APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.) WILD CARD WILD CARD W WILD CARD WILD CARD W WILD CARD WILD CARD W Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Perspectives on Management 2 Brent Braveman, PhD, OTR/L, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Identify and explain the commonly identified key functions of managers; ■ Provide examples of how occupational therapy managers would be involved in financial management, the development and assessment of competency, marketing, program development, and continuous quality improvement; and ■ Identify questions for further exploration on the relationship among leadership, management, and supervision. KEY TERMS AND CONCEPTS • • • • • • • • Competency Competency statements Continuous quality improvement Controlling Control mechanism Directing Environmental assessment Management • • • • • • • • Market analysis Marketing Marketing communications Middle managers Needs assessment Organizing Organizational assessment Plan–Do–Study–Act Cycle OVERVIEW M anagers play a critical role in organizations, including hospitals, schools, community-based organizations, skilled nursing facilities, private practices, businesses, and other organizational settings in which occupational therapy practitioners provide services. While some occupational therapy managers rise to top positions in organizations, many may be considered middle managers, meaning that they oversee a department or group of services, coordinate subordinates or employees, and report up the chain of command to a superior who may be a top leader in the organization. These managers are in the middle of the organization and are accountable to those above and below them in the organizational chart (see Figure 2.1). Managers are key to translating the mission and vision of the organization to employees at all levels by connecting their everyday tasks to the larger scope and mission. Managers help employees in making simple, everyday work • • • • • • • • Planning Program development Program evaluation Program implementation Program planning Staffing Strategic planning Value-based leadership activities important. This chapter provides an overview of the roles and functions of occupational therapy managers. ESSENTIAL CONSIDERATIONS Background and History Before the Industrial Revolution, there was not much “management.” Typically, the only person involved in management functions in business was the owner (McGrath, 2014). However, this changed with the rise of the Industrial Revolution as organizations grew larger and adopted new means of producing goods. McGrath (2014, para. 4) noted that “to coordinate these larger organizations, owners needed to depend on others, which economists call ‘agents’ and the rest of us call ‘managers.’” Early pioneers in occupational therapy played the role of manager in many ways, and management further gained a stronghold in 1984 when the American Occupational Therapy Association’s (AOTA’s) Administration & Management Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.002 19 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Perspectives on Management 2 Brent Braveman, PhD, OTR/L, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Identify and explain the commonly identified key functions of managers; ■ Provide examples of how occupational therapy managers would be involved in financial management, the development and assessment of competency, marketing, program development, and continuous quality improvement; and ■ Identify questions for further exploration on the relationship among leadership, management, and supervision. KEY TERMS AND CONCEPTS • • • • • • • • Competency Competency statements Continuous quality improvement Controlling Control mechanism Directing Environmental assessment Management • • • • • • • • Market analysis Marketing Marketing communications Middle managers Needs assessment Organizing Organizational assessment Plan–Do–Study–Act Cycle OVERVIEW M anagers play a critical role in organizations, including hospitals, schools, community-based organizations, skilled nursing facilities, private practices, businesses, and other organizational settings in which occupational therapy practitioners provide services. While some occupational therapy managers rise to top positions in organizations, many may be considered middle managers, meaning that they oversee a department or group of services, coordinate subordinates or employees, and report up the chain of command to a superior who may be a top leader in the organization. These managers are in the middle of the organization and are accountable to those above and below them in the organizational chart (see Figure 2.1). Managers are key to translating the mission and vision of the organization to employees at all levels by connecting their everyday tasks to the larger scope and mission. Managers help employees in making simple, everyday work • • • • • • • • Planning Program development Program evaluation Program implementation Program planning Staffing Strategic planning Value-based leadership activities important. This chapter provides an overview of the roles and functions of occupational therapy managers. ESSENTIAL CONSIDERATIONS Background and History Before the Industrial Revolution, there was not much “management.” Typically, the only person involved in management functions in business was the owner (McGrath, 2014). However, this changed with the rise of the Industrial Revolution as organizations grew larger and adopted new means of producing goods. McGrath (2014, para. 4) noted that “to coordinate these larger organizations, owners needed to depend on others, which economists call ‘agents’ and the rest of us call ‘managers.’” Early pioneers in occupational therapy played the role of manager in many ways, and management further gained a stronghold in 1984 when the American Occupational Therapy Association’s (AOTA’s) Administration & Management Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.002 19 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 20 SECTION I. Foundations of Occupational Therapy Leadership and Management FIGURE 2.1. A sample and abbreviated organizational chart. Board of Trustees Chief Executive Officer Vice-President Clinical Support Services Chief Medical Officer Vice-President Nursing Chief of Cardiology Chief of PM&R Staff Physicians Staff Physicians Director of Rehabilitation Director of Social Work Nursing Directors OT/PT/SLP Staff SW Staff Nursing Staff Source. Adapted from Braveman (2016, p. 113) with permission. Note. Due to space limitations only a few departments are shown. A real hospital organizational chart might be more complex and include many more departments. OT = occupational therapist; PM&R = physical medicine and rehabilitation; PT = physical therapist; SLP = speech–language pathologist; SW = social work. Special Interest Section (AMSIS) was officially created and the first AMSIS Quarterly was published in 1985. In 2017, AOTA changed the Special Interest Sections’ structure and AMSIS no longer exists as a separate SIS. Instead, each of the 9 SIS groups includes a position dedicated to administration and management titled the “Leadership and Management Coordinator.” Today, it is common for occupational therapy practitioners to assume the role of managers, and the accreditation standards for entry-level education for occupational therapy practitioners include multiple standards related to management (Accreditation Council for Occupational Therapy Education, 2018). Management vs. Leadership and Supervision Management is defined as “the process of guiding an organization by planning for future work obligations, organizing employees into functional units, directing employees in the process of completing daily work tasks, and controlling work processes and systems to assure adequate quality of work output” (Braveman, 2016, p. 6). It is difficult to have a discussion of management without addressing the topics of leadership and supervision. Leadership is “a process of creating structural change wherein the values, vision, and ethics of individuals are integrated into the culture of a community as a means of achieving sustainable change” (Braveman, 2016, p. 6). Supervision is “the control and direction of the work of one or more employees in a manner that promotes improved performance and a higher-quality outcome” (Braveman, 2016, p. 187). These 2 topics are addressed in more depth in other chapters in this textbook. Effective managers who also function as leaders use behaviors associated with these theories in their everyday work. For Additional Learning For additional learning, see Chapter 1, “Theories of Leadership.” An important consideration in the manager–leader connection is that of value-based leadership, which Durante (2016) described as “a model where the values of all stakeholders create an organizational code of standards and ethics that enables individuals to make independent decisions aligned to the organization’s values” (p. 662; see also Mendonca & Kanungo, 2007). Peregrym and Wollf (2013) defined values-­based leadership as “consistently leading out of personal values that are both desirable and beneficial for ourselves, those in our communities, and/or the organizations we serve” (p. 5). Value-based leaders concentrate on the core values of the organizations in which they work and view these values as directing principles that shape the behavior and action of the members of the organization (van Niekerk & Botha, 2017). Value-­based leaders use their values to transcend the everyday and create environments in which employees can concentrate on what is most important to the core work of the organization. Traditional Management Functions Braveman (2016) observed that most introductory texts on management identify 4 traditional management functions: (1) planning, (2) organizing (and sometimes staffing), (3) directing, and (4) controlling. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 2. Perspectives on Management Planning Planning is the process of establishing short- and long-term goals, measurable objectives, and action plans related to the organization’s mission. Goals are usually distinguished from objectives in terms of the scope of the accomplishment. Managers can be involved in different types of planning, including day-to-day operational planning, financial planning, long-term strategic planning, and planning for space and facilities, among others. Planning relates closely to the other management functions and includes determining the needs for the human resources, materials, supplies, facilities, and equipment. Developing the procedures to support the identified goals and objectives and documenting these procedures along with policies can help guide the use of materials, supplies, facilities, and equipment. Managers are responsible for planning the operational or day-to-day activities within a department and organization, but they are also responsible for longer term planning. This longer term planning, commonly referred to as strategic planning, is the process of determining the long-term goals of an organization, developing concrete measures of success and achievement, and formulating the strategies and general action plans to accomplish these goals. One of the most important planning responsibilities of many managers is the development and oversight of a department budget (i.e., financial planning). For Additional Learning For additional learning, see Chapter 9, “Strategic Planning.” Another type of complicated planning that managers may encounter is planning the spaces and facilities in which occupational therapy practitioners work. Space planning has important implications for the flow of occupational therapy clients and the everyday work of occupational therapy practitioners. Space planning is typically completed as part of a team with consultation from professional space planners or engineers because of its complexity. Organizing Organizing (which sometimes includes staffing) is the process of designing workable units, determining lines of authority and communication, and developing and managing patterns of coordination. Organizing involves creating the most effective grouping of activities together with the necessary guidelines and coordinating systems so that the organization’s goals can be achieved as efficiently as possible. The management function of organizing typically serves to answer these questions: ■ Who is responsible for work tasks and outputs of critical work processes? 21 and that these persons have the necessary skills to do the job. Staffing ensures that the organization will have sufficient quantity and quality of personnel to achieve its mission and goals. This ongoing process accounts for recruiting, hiring, training, firing, and replacing personnel as necessary. Directing Directing is the “process of providing guidance and oversight so that the work performed is goal oriented and focused on achieving desired departmental and organizational outcomes” (Braveman, 2016, p. 175). The manager must lead employees and motivate them to work toward achieving organizational goals and objectives. Mentoring and coaching are directing activities, as is correcting difficult employee behavior through discipline or even separation if an employee cannot alter work performance and behavior to meet expectations. Controlling Controlling is the process of measuring actual performance against expectations and guiding staff to overcome obstacles to achieve desired outcomes. The use of control mechanisms or control indicators is one way to perform the controlling function. A control mechanism or control indicator is a “check” or measure that is in place to constantly monitor the output or product of a system. When the check reveals that performance falls below a previously established limit, it indicates that unacceptable variation has entered the work processes. The check is the cue to take action by correcting or adjusting relevant work processes. In addition to checking workflows or processes, control mechanisms can assess expected outcomes or work products. The tools that managers use to implement and manage control mechanisms include policies, procedures, and documentation systems. Review Questions 1. What does it mean to be a middle manager? 2. What are key outcomes of leading from a values-based perspective? 3. What are the 4 commonly identified functions of managers? PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Occupational therapy managers carry out the traditionally identified management functions in different combinations to complete the varied responsibilities they face in their daily work. A few of these responsibilities are described in the following sections of this chapter. ■ Who has the authority to make decisions? ■ How will work activities be functionally separated? ■ What are the expected levels of performance for individu- Developing and Assessing Staff and Managerial Competencies Staffing is the process of ensuring that the right person is completing the right tasks within predetermined work units An important role of managers is to assess and ensure the competency of staff. Competency is “an individual’s actual performance in a particular situation” (Braveman, 2016, p. 298). als and groups? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 22 SECTION I. Foundations of Occupational Therapy Leadership and Management Managers are typically responsible for identifying the essential work functions included in the job descriptions for each position they oversee and determining whether employees can meet the competency standards required to work in a particular setting. Managers do so by identifying competency statements or checks, which are “explicit measures, indicators, or statements that define specific areas of knowledge, skills and abilities related to essential functions and assigned duties” (Braveman, 2016, p. 298). A helpful resource from AOTA is its Standards for Continuing Competence (AOTA, 2015). After staff is trained, managers assess competencies by using several methods, including observation, written tests, return demonstration, or critical reasoning exercises. Competencies can range widely depending on the practice setting. Examples of competencies include making a resting hand splint that meets set criteria, safely applying a therapeutic modality, or demonstrating cultural sensitivity during an occupational therapy evaluation. Competencies also can be identified related to managerial roles. Areas often cited as necessary for a manager to practice competently include professionalism, leadership, knowledge of health care systems, business knowledge and skills, problem solving, gathering and synthesizing information, interpersonal communication, team management and coaching, and continuous quality improvement. Financial Management Financial management, financial planning, and the development and oversight of a department budget are important functions of many occupational therapy managers. Budgeting is both a planning and a controlling function. It involves planning because managers must project the financial impact of meeting clients’ needs, and it involves controlling because managers must set limits on the everyday activity of staff and their salary, as well as other forms of compensation and rewards to staff for doing their jobs. Developing and managing a budget can be a complex process; occupational therapy practitioners who have the goal of becoming a departmental manager or director are encouraged to obtain knowledge and develop skills far beyond what they will learn in an entry-level occupational therapy program. Technology and Management Managers must become familiar with the use and application of a wide range of technologies. These technologies include business, information, and communication technologies that are used to run the business of the organization and, in many settings, clinical technologies that are used in interventions with clients. Examples of business, information, and communication technologies include analytical software, data storage and analysis technologies, and technologies to run virtual meetings or collaborate with others in real time. An electronic health record is another example of an information technology that is common in many settings today. Examples of clinical technologies include physical agent modalities, ultrasound machines, driving simulators, and technologies to assess vision. Managers often must become adept at learning how to evaluate the cost and benefit of technologies that they have not personally used in clinical practice. Marketing Marketing is “the management process through which goods and services move from concept to the customer. It includes the coordination of four elements called the 4 P’s of marketing” (Businessdictionary.com, 2017), which include the (1) development and definition of products produced by the organization, (2) price, (3) place or where the product is delivered, and (4) development of a promotional strategy. When thinking of marketing, it may be tempting to immediately think about promoting a product. After all, one is confronted almost every day with constant promotional messages in all forms of advertising. However, much of the marketing process happens before one ever sees a print, television, radio, or online promotion. There are 4 components of the marketing process: 1. Organizational assessment involves examining what will influence the development and promotion of a new product or service. This includes identifying strengths and weaknesses through a SWOT (strengths, weaknesses, opportunities, threats) analysis. 2. Environmental assessment involves examining the needs of target populations that guide the development and promotion of a new product or service. 3. Market analysis involves validation of the perceptions of the wants and needs of the target populations that will receive a new product or service. 4. Marketing communications involves packaging and promoting a product so the target populations and other key stakeholders have a clear understanding of what the product or service is and how it may be accessed. Program Development Program development is the process of formulating orga­ nized elements of service to meet a set of predetermined and desired clinical goals and outcomes. It is common for occupational therapy managers to develop, plan, implement, and evaluate occupational therapy programming. The level of complexity of program development can vary greatly. An example of a relatively simple program development might be adding a new element of service delivery to an existing program and a known population, such as adding a pread­ mission or prehabilitation visit for a client who will undergo a stem cell transplant when one is already providing inpa­ tient and postdischarge outpatient services to these clients. However, program development can also be complicated and challenging. An example would be designing a population health initiative for a community to address the occupational needs of new immigrants displaced by war and military struggles. Managers who are developing Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 2. Perspectives on Management 23 TABLE 2.1. Commonly Used Tools and Techniques in Continuous Quality Improvement TOOL OR TECHNIQUE USE OR APPLICATION Brainstorming Technique to generate a large number of ideas in a short period of time Cause-and-effect (fishbone) diagram Diagram that relates identified causes to the problem (effect) being studied Check sheet Standardized tool developed for manual data collection Histogram Bar graph that shows the distribution of a set of data; each bar on the horizontal axis represents a subset of data, whereas the vertical axis indicates number or frequency Nominal group technique/multivoting Team voting method Pareto chart Bar graph that includes a second vertical axis to demonstrate cumulative percentage; the chart is used to identify the vital few causes of a problem PDSA (Plan–Do–Study–Act) Cycle Systematic, repeatable, and teamwork-based process for solving problems or realizing opportunities for enhanced performance at the organizational, system, process, and employee levels in order to achieve desired results Process flowchart Graphical representation of the steps and decisions in a process Run chart Graph that shows measurement (on the vertical axis) against time (on the horizontal axis) occupational therapy or interprofessional programs rely on and use paradigmatic knowledge, including theories, frames of reference, and conceptual practice models, as well as related knowledge developed in other disciplines and fields. Various program development models or frameworks exist in the literature of the occupational therapy profession and related fields, but what follows is a simple 4-step model for understanding the program development process. 1. Needs assessment: The process of describing the target population, naming perceived and felt needs, and analyzing available resources and constraints both internal and external to the organization or context in which the program is being planned. 2. Program planning: The process of identifying the steps and sequence of actions to be taken to plan for initiation of the program. 3. Program implementation: The process of initiating intervention first in trial format and then in a more formal and sustained manner. 4. Program evaluation: The ongoing process of assessing the impact and quality of program processes and outcomes and making continuous improvements in efficiency and effectiveness. Continuous Quality Improvement Continuous quality improvement (CQI) is both a management philosophy and a management method. As a management philosophy, CQI takes an organizational perspective: setting direction and promoting strategically aligned improvement initiatives through leadership support, organiza­ tional learning, and resource allocation. As a management method, CQI provides a framework for identifying improvement opportunities and managing CQI teams tasked with analyzing problems so that solutions can be identified and implemented; in this way, desired results are achieved. CQI approaches such as the Plan–Do–Study–Act (PDSA) Cycle are commonly used in health care (W. Edwards Deming Institute, 2014). The PDSA Cycle includes these 4 steps: 1. Plan: The change to be tested or implemented 2. Do: Carry out the test or change 3. Study: Examine the data before and after the change and reflect on what was learned 4. Act: Plan the next change cycle or full implementation. A short list of commonly used CQI tools and techniques is included in Table 2.1. Review Questions 1. What is the purpose of a competency statement or check, and how is it used by occupational therapy managers? 2. What traditional management function would include financial management? Why? 3. Name the 4 components of the marketing process and explain their purpose. 4. Briefly describe the 4 steps of the program development process. 5. Is continuous quality improvement a management philosophy, a management method, or both? Explain your answer. SUMMARY The role of occupational therapy managers can be complex and includes a wide range of activities and functions. Most of Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 24 SECTION I. Foundations of Occupational Therapy Leadership and Management CASE EXAMPLE 2.1. Robin: Starting as a New Occupational Therapy Manager Robin is a new occupational therapy manager in a small occupational therapy department in a community-based acute care hospital. She has recently completed her orientation and has taken stock of priorities for the department and the team she will lead. She is anxious to apply all she has learned about being an occupational therapy manager. Robin begins by thinking through her primary responsibilities and uses the 4 traditional management functions of planning, organizing, controlling, and directing as a framework to be sure she is not overlooking anything important. She also begins an assessment of her skills and areas for improvement as a leader, manager, and supervisor. Robin completes the important step of thinking about both the personal values that she holds and wants to exemplify as a leader and the values of the organization that she has just joined. She begins to think about ways she can demonstrate her values of transparency, respect for others, constant learning and discovery, and serving others as a leader. She also considers how she can demonstrate the organizational values of caring, innovation, and person-centered care in her leader behaviors. Robin decides to involve her staff in some visioning activities to include them in planning the future of the department and uses the results, along with the results of a SWOT analysis, to begin a strategic plan. The plan will guide her focus and the focus of her staff for the next 3 years. She also reaches out to others, such as physicians, nurses, physical therapists, case managers, and social workers, as key stakeholders in the products her department provides for the organization. Robin knows she has much to learn, including how to plan and manage the department finances, a responsibility that will be new for her. During the interview process, she learned that demand for occupational therapy services was growing and that with the development of new medical services lines (i.e., cancer rehabilitation in an inpatient rehabilitation unit), she would need to develop new occupational therapy programming. She begins this process by assessing the current competencies of her staff and their needs for learning in new areas. She introduces her staff to the principles of CQI and begins to guide them through the PDSA process to examine how they receive and schedule initial evaluations in the hopes of making this process more efficient. During this process, she begins to use CQI tools such as a fishbone diagram (see Figure 2.2). It’s just a start. As Robin continues to learn, she is confident that if she lets her values guide her, she will succeed. Review Questions 1. 2. 3. What is the PDSA process, and how is it related to CQI and improving efficiency in scheduling initial evaluations? What is values-based leadership, and how can it help to guide Robin’s decisions and actions? What are competencies, and how can Robin use them to plan and deliver occupational therapy services in her organization? FIGURE 2.2. Fishbone diagram on causes for extended time to receive and schedule initial evaluations. CAUSES OF EXTENDED TIME TO RECEIVE AND SCHEDULE INITIAL EVALUATIONS Technology Use of paper logs instead of electronic No downtime procedure Incompetent employees People Too busy to attend to referrals Forget to log new referrals Too long to receive and schedule initial evaluations Duplication in steps No standardization Assignment process is confusing Processes Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 2. Perspectives on Management these activities can be grouped under the commonly identified functions of managers that include planning, organizing (and sometimes staffing), controlling, and directing. Effective managers also function as leaders, and 1 model of leadership to consider is that of values-based leadership. Leaders who lead from a values-based perspective can help employees to connect their everyday work to the core functions and mission of the organization. The topics addressed in this chapter and a range of other topics related to the occupational therapy manager are explored in the remaining chapters of this textbook. Case Example 2.1 describes a new occupational therapy manager learning to lead from a values-based perspective. ❖ LEARNING ACTIVITIES 1. At the start of the chapter, the difference between management and leadership was introduced, as was the concept of values-based leadership. Reflect on (a) your personal values, (b) the values of the occupational therapy profession, and (c) the values you hope organizations that you work for will hold. What would be possible strategies for coming to terms with any conflicts you encounter between your personal values and the values of the occupational therapy profession or an organization? Where would you begin if you perceived a conflict in values? How might you use resources provided by AOTA? 2. Working as an occupational therapy manager and completing the wide variety of tasks and responsibilities that fall to most managers is complex. Reflect on your current skills and experiences, and consider what learning or growth activities you could pursue if you were interested in a job as an occupational therapy manager or found yourself in a position where you had to manage occupational therapy services for a time. What strengths do you have that you could leverage, and what areas would you need to focus on most to begin a path toward being an effective occupational therapy manager? ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ ■ ■ ■ ■ B.4.25. Principles of Interprofessional Team Dynamics B.4.27. Community and Primary Care Programs B.4.29. Reimbursement Systems and Documentation B.5.1. Factors, Policy Issues, and Social Systems B.5.3. Business Aspects of Practice. ■ ■ ■ ■ ■ 25 B.5.4. Systems and Structures That Create Legislation B.5.5. Requirements for Credentialing and Licensure B.5.6. Market the Delivery of Services B.5.7. Quality Management and Improvement B.5.8. Supervision of Personnel. For Additional Learning For additional information about concepts discussed in this chapter, please refer to ■ ■ ■ ■ Chapter 1, “Theories of Leadership,” Chapter 9, “Strategic Planning,” Section VI, “Supervision,” and Chapter 50, “Developing a Budget.” REFERENCES Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org /10.5014/ajot.2018.72S217 American Occupational Therapy Association. (2015). Standards for continuing competence. American Journal of Occupational Therapy, 69, 6913410055. https://doi.org/10.5014/ajot.2015.696S16 Braveman, B. (2016). Leading and managing occupational therapy services: An evidence-based approach. Philadelphia: F. A. Davis. Businessdictionary.com. (2017). Marketing. Retrieved from http:// www.businessdictionary.com/definition/marketing.html Durante, R. (2016). Value-based leadership and personality type: The influence on organizational culture. In V. C. X. Wang (Ed.), Encyclopedia of strategic leadership and management (pp. 662–685). Hershey, PA: IGI Global. McGrath, R. G. (2014). Management’s three eras: A brief history. Retrieved from https://hbr.org/2014/07/managements-three-eras -a-brief-history Mendonca, M., & Kanungo, R. N. (2007). Ethical leadership. New York: Open University Press. Peregrym, D., & Wollf, R. (2013). Values-based leadership: The foundation of transformational servant leadership. Journal of Value-­ Based Leadership, 6(2), Art. 7. Retrieved from https://scholar.valpo .edu/cgi/viewcontent.cgi?article=1084&context=jvb van Niekerk, M., & Botha, J. (2017). Value-based leadership approach: A way for principals to revive the value of values in schools. Educational Research and Reviews, 12, 133–142. https://doi.org .10.5897/ERR2016.3075 W. Edwards Deming Institute. (2014). PDSA Cycle. Retrieved from https://deming.org/explore/p-d-s-a Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Leadership vs. Management: Differences and Skill Sets CHAPTER 3 Debi Hinerfeld, PhD, OTR/L, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Differentiate between leadership and management intentions or behaviors, ■ Discuss how a blended approach of leadership and management promotes effective team work and continuity of leadership in the future, and ■ Recognize themselves as leaders and begin to develop a personal leadership trajectory and action plan. KEY TERMS AND CONCEPTS • Interprofessional health • • care teams Leaders Leadership • • • • OVERVIEW L • Transformational • Values • Vision Management Managers Paradigm shift Power eadership and management are 2 different but integrally related skill sets that are critical to organizational success in a rapidly changing health care environment. To understand and appreciate leadership requires a paradigm shift, which is a change in beliefs from those previously held about managerial approaches used in the past. Current concepts of leadership are focused on a distribution of power from an individual to a team that works collaboratively to develop proactive and innovative solutions to organizational challenges. Management has always been based on the administrative authority of someone who plans, organizes, directs, and controls employees in their daily tasks and maintains stability and consistency of individuals’ work. Today’s challenges create a strong demand for both leadership and management for organizations to prosper in uncertain times. The Triple Aim of health care reform, which was designed to reduce costs while improving quality and efficiency of services, has a significant impact on health care; it focuses on “interprofessional primary health care, new models for payment, and an emphasis on value as demonstrated through improved outcomes” (Lamb, 2016, p. 3). In response, health care organizations seek professionals who can be instrumental in the administrative processes of planning, communicating, implementing, and sustaining an organization as well as assist in strengthening and moving their organizations forward while managing change (Phipps, 2015). At the same time, strong leaders are needed to advocate effectively for the distinct value of occupational therapy in new service delivery models, not only in their organizations but also in policy decision-making circles, to ensure that occupational therapy becomes a highly valuable and viable solution during health care reform (Lamb, 2016). This chapter seeks to differentiate leadership and management on the basis of intentions and behaviors, guiding readers toward an understanding of how a combination of approaches helps move organizations and advocacy efforts forward in meaningful and effective ways. This chapter also discusses the importance of the concept that “every member [be] a leader” (Stoffel, 2014, p. 634) and practical ways that occupational therapy practitioners can further develop their leadership capacities. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.003 27 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Leadership vs. Management: Differences and Skill Sets CHAPTER 3 Debi Hinerfeld, PhD, OTR/L, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Differentiate between leadership and management intentions or behaviors, ■ Discuss how a blended approach of leadership and management promotes effective team work and continuity of leadership in the future, and ■ Recognize themselves as leaders and begin to develop a personal leadership trajectory and action plan. KEY TERMS AND CONCEPTS • Interprofessional health • • care teams Leaders Leadership • • • • OVERVIEW L • Transformational • Values • Vision Management Managers Paradigm shift Power eadership and management are 2 different but integrally related skill sets that are critical to organizational success in a rapidly changing health care environment. To understand and appreciate leadership requires a paradigm shift, which is a change in beliefs from those previously held about managerial approaches used in the past. Current concepts of leadership are focused on a distribution of power from an individual to a team that works collaboratively to develop proactive and innovative solutions to organizational challenges. Management has always been based on the administrative authority of someone who plans, organizes, directs, and controls employees in their daily tasks and maintains stability and consistency of individuals’ work. Today’s challenges create a strong demand for both leadership and management for organizations to prosper in uncertain times. The Triple Aim of health care reform, which was designed to reduce costs while improving quality and efficiency of services, has a significant impact on health care; it focuses on “interprofessional primary health care, new models for payment, and an emphasis on value as demonstrated through improved outcomes” (Lamb, 2016, p. 3). In response, health care organizations seek professionals who can be instrumental in the administrative processes of planning, communicating, implementing, and sustaining an organization as well as assist in strengthening and moving their organizations forward while managing change (Phipps, 2015). At the same time, strong leaders are needed to advocate effectively for the distinct value of occupational therapy in new service delivery models, not only in their organizations but also in policy decision-making circles, to ensure that occupational therapy becomes a highly valuable and viable solution during health care reform (Lamb, 2016). This chapter seeks to differentiate leadership and management on the basis of intentions and behaviors, guiding readers toward an understanding of how a combination of approaches helps move organizations and advocacy efforts forward in meaningful and effective ways. This chapter also discusses the importance of the concept that “every member [be] a leader” (Stoffel, 2014, p. 634) and practical ways that occupational therapy practitioners can further develop their leadership capacities. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.003 27 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 28 SECTION I. Foundations of Occupational Therapy Leadership and Management ESSENTIAL CONSIDERATIONS Current health care challenges in the United States require an understanding and a strong belief in systemic, postindustrial managerial approaches that are visionary, collaborative, and interprofessional, rather than reactive, hierarchical, and authoritative (Komives, 2013). Beliefs around management and leadership can be construed and misconstrued through different assumptions based on power, defined as influence, control, or authority over others (Edwards et al., 2015; “Power,” n.d.). Although there are notable differences between a pure managerial approach and a pure leadership approach, the differences between management and leadership are primarily based on intention and behaviors. Differences Between Management and Leadership Theorists on management and leadership believe that despite similarities between leadership and management approaches, very distinct differences exist between them. Functions and behaviors of management do not automatically translate into leadership. Rather, leadership is determined by a person’s behavior and overall effectiveness while guiding others toward the achievement of organizational goals. In hierarchical organizational structures, managers often manage through an authoritative approach to the achievement of short-term organizational goals, directing others through a specific chain of command (Carpenter et al., n.d.; Cox, 2016). Leadership is a highly relational and ethical process that inspires individuals to work together to create necessary changes that effectively move an organization toward an ideal model of the future despite challenges. Leaders serve others and develop future leaders. Both leaders and managers establish direction, align resources, and motivate teams toward organizational goals. Although management is focused on planning, organizing, directing, and controlling day-to-day employee tasks, leadership is a strategic approach focused on inspiring and empowering teams to pave alternative paths in organizational processes that make it possible to achieve the collective vision. Leaders create vision, managers set goals. A vision represents an ideal model of the future that implies change and challenges organizations to transcend the status quo (Phipps, 2015). Leaders inspire others by enthusiastically communicating a clear and compelling vision that influences actions toward the achievement of organizational goals (Kouzes & Posner, 2017; Kruse, 2013; Surbhi, 2015). The vision brings individuals together for common purposes. It focuses team efforts on the horizon while navigating challenges presented by a constantly changing external environment. Managers dutifully oversee employees’ work toward the achievement of predictable and short-term objectives. They are mainly concerned with individual performance and measurement of outcomes that are focused on operations with little regard to external forces that can have a tremendous impact on the viability of the organization in changing times. Leaders focus on relationships, managers focus on operational procedures. Leaders focus on people, whereas managers focus on the completion of established procedures. By developing strong relationships with others, leaders know who their teams and stakeholders are and how best to serve them. They establish direction by setting the bar high, aligning resources, inspiring, and motivating people to move the organization forward despite challenges. Leaders trust that their teams are equally passionate about the vision and empower teams to be innovative. Leaders create a culture of community and do not micromanage to ensure that people are engaged in meaningful work that motivates them to work at higher levels. They publicly recognize and celebrate individual and team contributions, provide social outlets to support collaboration, and demonstrate that they care by being personally involved (Kouzes & Posner, 2017). Management focuses on getting work done through people and processes, relying on authority and control to keep people and projects moving forward. Managers assign and closely supervise tasks, often with little input from the individuals carrying out the job. They set standards, establish consistency and predictability, and create order (Arruda, 2016). Leaders inspire and empower, managers direct and control. It is no longer believed that leaders must have special attributes or titles to influence and motivate others to join them in leadership efforts (Kruse, 2013). Leaders inspire others by being authentic, which comes from an acute self-awareness and the ability to be honest about personal beliefs, values, attitudes, and emotions. Behaving in ways that are congruent with their beliefs and values, personal expressions of what is important to them, leaders model the way, setting examples for others to do the same (Kouzes & Posner, 2017). Leaders empower teams by providing all necessary resources and clearing the path of obstacles so that they can strategically focus on necessary changes and desired outcomes. Managers are responsible for delegating responsibilities and evaluating performance. Although directing and controlling employees ensures that they are responsibly doing the job that they were hired to do, it is also important that employees are engaged in meaningful, satisfying work to encourage high performance (Carpenter et al., n.d.; Cox, 2016). Leaders challenge the process, managers maintain the status quo. Leaders support good ideas and encourage risk taking in support of innovative best practices (Phipps, 2015). They are flexible, forward thinking, enthusiastic, and confident, and they are willing to try something new that could support the team’s mission and vision. They fully realize that change is often a byproduct Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 3. Leadership vs. Management: Differences and Skill Sets 29 TABLE 3.1. Complementary Process Differences Between Leaders and Managers PROCESS LEADER MANAGER Developing a plan ■ Establishes direction ■ Envisions the future ■ Is Passionate about the vision and facilitates change ■ Plans and budgets ■ Assigns action and sets schedules ■ Allocates resources Developing people ■ Aligns people with goals ■ Communicates vision and strategy ■ Establishes teams ■ Organizes staffing ■ Develops policies and procedures ■ Monitors progression of work Operations ■ Motivates and inspires ■ Removes obstacles and barriers to success ■ Controls ■ Short-term problem solver ■ Focused on order, predictability, and consistency Outcomes ■ Focused on change ■ Monitors results against plan and takes corrective action Source. Adapted from Kotterman (2006). of innovation, and they empower their teams to think creatively about alternative paths moving forward. Although innovation may result in failure, leaders understand that failure is often a critical step toward success and that much can be learned from what did not work the first time (Arruda, 2016). Managers are more likely to take a low-risk approach to problem solving because their focus is on short-term decision making, bringing stability to processes that have always worked in the past rather than thinking about how to do things differently in the future. They avoid risk of failure by reactively controlling problems, developing process steps, and setting timelines for accomplishment when something gets out of sequence or control (Bârgău, 2015; Ross, 2014). Leaders believe in lifelong leadership development, managers maintain existing skills. Leaders believe that learning is a lifelong process and that their development is never complete. They are seekers of information and higher-level leadership experiences that expand and diversify their skills. Leaders strengthen the leadership capacities of others by engaging them in meaningful experiences, whereby the cycle of leadership grows exponentially as those leaders continue the process (Solomon et al., 2016). Because management is based on completing predictable tasks, managers typically rely on existing skill sets that have enabled employees to perform successfully. Managers who take a management approach may perfect the execution of tasks with practice, but they are not necessarily focused on developing higher level skills for themselves or others. Leadership and Management as Complementary Approaches With the many changes affecting the health care industry, now is certainly not the time to take a 1-size-fits-all approach to business operations. Management with insufficient leadership can be overbearing and bureaucratic, and leadership without management can lead to inefficient efforts toward purposeless outcomes. At the highest level of guidance toward envisioned outcomes, leaders and managers must have complementary skill sets and adopt a blended approach (Delmatoff & Lazarus, 2014). See Table 3.1 to understand how leadership and management processes complement each other. Taken together, management and leadership are considered transformational because they prompt both leaders and followers to adhere to higher levels of ethical aspirations and conduct when pursuing a shared purpose toward organizational change (Komives, 2013). Effective transformational leadership is critical to sustaining long-term efforts toward the vision, particularly during health care reform when change is inevitable (Phipps, 2015). Transformational leaders must be able to create an inspirational vision and build organizational capacities to manage change that leads to better health care solutions. Rapid changes in the health care environment, however, require effective management to ensure organizational sustainability (Trastek et al., 2014). During challenging times, transformational leaders inspire employees toward an optimistic future by meaningfully engaging them in decision-making processes, problem solving, and creating solutions that support systems improvement and project management (Gousy & Green, 2015; Phipps, 2015). As organizations implement strategic change in response to new policy mandates and diverse payer models, a transformational approach is necessary to maintain high engagement and forward momentum at all employee levels. Transformational leaders create a culture of leadership by which employees lead one another in efforts toward the vision while the leader effectively manages resources that support their work. Review Questions 1. The difference between leadership and management is based on a. Values and power b. Intentions and behavior c. Control and budgeting d. Directing and planning Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 30 SECTION I. Foundations of Occupational Therapy Leadership and Management 2. In hierarchical organizational structures, managers often take an approach to the achievement of shortterm organizational goals. a. Organized b. Repetitive c. Authoritative d. Friendly 3. A vision represents an ideal model of the future that implies a. Progress b. Change c. Status quo d. Acuity PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Occupational therapy leaders have been successful in expanding practices in alternative practice settings and have improved public awareness of occupational therapy over the past 100 years. The American Occupational Therapy Association (AOTA) has positioned the profession well toward Vision 2025, which is designed to “maximize health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living” (AOTA, 2017b, p. 1). However, as current occupational therapy leaders begin to retire and significant changes continue to happen in the world, there is a critical need for every occupational therapy practitioner to practice leadership to continue moving the profession forward, particularly during challenging times. Developing Occupational Therapy Leaders Regardless of title or position, leadership is everyone’s business (Stoffel, 2014). It is crucial that the profession of occupational therapy develop leaders in all areas of practice, research, and education to sit confidently at policy and payment decision-making tables (Stoffel, 2014). Developing occupational therapy leaders will generate a collective power that is necessary to clearly articulate the distinct value of the profession as a client-centered and occupation-based profession, to develop strong evidence behind occupational therapy practices, to provide quality and cost-effective services, and to ensure inclusion in new health care and payment models. Knowing that leaders are developed, and believing that everyone has the capacity to become a leader, occupational therapy practitioners have always been encouraged to take the leadership challenge and say “yes” to opportunities. Within organizational structures, occupational therapy practitioners are uniquely positioned to develop and demonstrate leadership capacities that easily translate into administrative positions in traditional as well as nontraditional areas, such as primary care, private practice, practice in underserved areas, and research (Rogers et al., 2016). Seeking Organizational Opportunities Employees have many opportunities to practice and develop leadership skills; they can serve on committees, participate in the development of new policies or procedures, conduct research, or organize professional development with colleagues. Occupational therapy practitioners have opportunities to develop their leadership skills while serving on interprofessional health care teams. Interprofessional health care teams comprise individuals from multiple health care disciplines who agree to share their point of view and expertise and are open to learning and sharing in a trusting environment to help solve organizational problems. These teams instill a sense of leadership in everyone regardless of hierarchical role, title, or position. It is through leadership actions, passion, and dedication that leaders continue to develop their own leadership skills and prepare to take on higher level leadership challenges. Identifying Values Leadership can be developed in any context of life and often occurs when one has very little awareness that it is happening. Mentoring a recent occupational therapy graduate who is new to practice, volunteering to organize social activities within the department, and describing occupational therapy to someone who has never heard about it before are all examples of leadership that builds on leadership capacities. Engagement in leadership often starts when one’s personal core values align with those of others who are also motivated to make a positive difference toward a greater good. People’s values inform their leadership practices and drive them to focus on what they believe, setting an example for others. (Readers can identify their core values by doing the values card sort activity in Appendix 1.A in Chapter 1, “Theories of Leadership.”) Authentically demonstrating core values through actions and words is the most powerful way that leaders influence others and have a broad impact. Becoming Lifelong Learners It is important that professionals become lifelong learners and understand how to find leadership development opportunities in different contexts of practice. Practitioners should always have a long-range plan and consider where they want to be in 5 or 10 years to establish time frames for advancing career goals. Occupational therapy students and practitioners must envision themselves as future administrators, department heads, team leaders, board or specialty certified practitioners, clinical education coordinators, professors, postgraduate fellows, CEOs of a health care company, or college or university presidents. Reflection on past leadership participation is important to realize leadership capacities that have been developed and to have the confidence to seek out higher level leadership op­ portunities when they present themselves in the future. Occupational therapy practitioners who serve in leadership roles grow professionally through their leadership experiences, Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 3. Leadership vs. Management: Differences and Skill Sets gaining skills in other critical professional areas such as strategic planning, management, interpersonal communication, and collaborative problem solving. Participating in Professional Organizations Occupational therapy practitioners have opportunities to develop their leadership skills not only in their jobs but also through their involvement in professional organizations. Practitioners who become lifelong members of their state occupational therapy association and AOTA are acknowledging that they are mindful of their professional responsibility and willing to support the profession as it moves into the next 100 years. These associations rely deeply on members’ financial support of valuable practice, legislative, and educational benefits and members’ volunteer efforts to help guide and shape the profession while it navigates a challenging future. Members have opportunities through state and national occupational therapy organizations to participate in legislative days at the state or national capital and meet their legislators and educate them on occupational therapy and its distinct value as an essential health service. Members may also practice advocacy by getting involved in grassroots letter or email writing campaigns to legislators on hot political topics that affect practice and patient access to occupational therapy services. Occupational therapy practitioners have opportunities to share their leadership and expertise by running for an elected position or applying for an appointment to an ad hoc or standing committee. Online continuing education on leadership development is available at a discount for all members of AOTA. Early career practitioners, middle managers, and educators have opportunities to apply for the AOTA mentored leadership development institutes offered annually. The profession of occupational therapy also benefits when occupational therapy leaders actively serve in their communities on organizational boards and committees; at organized events; and as political leaders to educate the public about the benefits of occupational therapy to individuals, communities, and populations. Modeling Self-Care Leaders who take care of themselves are better equipped to take care and serve others. It is important to evaluate work– life balance and time considerations when deciding to commit to a leadership opportunity. Leaders know that they must be present, available, accountable, and at their best to model and promote leadership for others. They are kind to themselves when they stretch themselves to grow, set short timelines, work hard but within their limitations, forgive themselves for responsible failure, and believe that success may come from second chances (Rockwell, 2017; see Case Example 3.1). Taking care to practice what we preach and engage in meaningful occupations such as eating and sleeping well, getting adequate exercise, taking time to play, and spending time with family and friends are all very important to remaining physically and mentally healthy and to continue functioning effectively in a leadership role. 31 Review Questions 1. Leaders and managers must have a complementary skill set and adopt what type of approach? a. Forced b. Visionary c. Blended d. Controlled 2. Transformational leadership can be described as everything listed except a. Inspiring b. Engaging c. Visionary d. Preventing change 3. Who should assume leadership of the profession of occupational therapy? a. AOTA Board members b. Only members of professional associations such as state occupational therapy associations and AOTA c. AOTA employees d. Everyone SUMMARY Leadership and management represent different but complementary administrative approaches. Having visionary, collaborative, and innovative teams is important; similarly, management processes such as planning, directing, budgeting, and organizing are also necessary to keep teams focused on goals and action plans that move organizations forward. This chapter describes leadership and management as separate skill sets and emphasizes that differences are based on interpersonal relationships, style, approach, behaviors, and perception of power. Health care administrators who use a blended leadership and management approach are more likely to benefit from the collective effort of engaged employees in efforts that move the organization forward, particularly in a challenging environment that is difficult to navigate. It is essential that occupational therapy practitioners consider the development of leadership skills as part of their professional development (see AOTA, 2015, for standards for continuing competence and AOTA, 2017a, for information on continuing professional development in occupational therapy). Occupational therapy leaders are needed at all levels of practice, education, and research to communicate the distinct value of the profession and to develop future leaders. Administrative leaders who are also occupational therapy practitioners are uniquely positioned to communicate how inclusion of occupational therapy in client services can support organizational efforts aimed at the challenge of providing quality care with fewer resources that also decreases overall health care costs. Authentic leaders inspire and motivate others by sharing values and establishing common purposes, developing strong relationships with team members, and allowing teams to be innovative; they challenge current processes that may be barriers to achieving the vision. Leaders are not afraid of failure Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 32 SECTION I. Foundations of Occupational Therapy Leadership and Management CASE EXAMPLE 3.1. Balancing the Roles of Leader and Manager Sue is the director of occupational therapy at a community-based outpatient wellness and rehabilitation center known for its positive, interprofessional, and highly supportive work environment and excellent patient care. She supervises 15 occupational therapy practitioners and directs operations of the department to ensure that her department is engaged in efforts to achieve the center’s vision to be the premier wellness and rehabilitation center in the city. As the director, Sue must balance her role as a manager with leading her staff toward excellent patient care and professional development. She values the diverse number of years of experience and specialty practice areas that each person brings to the department. Knowing that meaningful and challenging work as well as a friendly and collaborative work environment translates into more satisfied employees, Sue strives to ensure that each one of her employees has opportunities to grow professionally and have fun together. Everyone in the department appreciates knowing that Sue welcomes feedback on how the department is operating and that she values staff ideas and involvement in centerwide strategic initiatives. As a team, Sue and her staff recently discussed the increased productivity standards and determined that they were too high for the department. As a manager, Sue understands that it is necessary to balance staff concerns and professional ethics while maintaining the fiscal strength of the department. She took time to explain the fiscal goals of the department and appointed a team to develop innovative ideas that members of her department could implement to increase revenue, while maintaining ethical productivity standards. At staff meetings, Sue shares updates on centerwide initiatives and seeks ideas from her staff on how best to implement new processes with success. When an interdepartmental quality assurance initiative was being introduced, Sue asked Amy to attend interprofessional centerwide meetings and organize and lead efforts within the department. Amy is a new therapist but always has good ideas on how to manage risk in the clinic (e.g., by posting signs to clean up water spills or making sure that the oven is turned off after sessions). Amy was thrilled that Sue recognized her in this way and was excited to learn something new and be instrumental in leading her colleagues toward higher quality outcomes. While supervising a student, Matt had an idea to organize a journal club within the department that could help him and his colleagues become better evidence-based practitioners. Sue thought this was a wonderful idea. She not only gave Matt and his student time to organize and plan for a monthly journal club but also went to the center administrator to request a subscription to an online journal repository so that all practitioners could have access to current research for their discussions and for future reference. As an occupational therapy practitioner, Sue feels strongly that it is a professional responsibility to be a member of both the state and national occupational therapy associations; she regards it as professionally beneficial as well. She believes that when people come together collectively, they are more powerful in influencing policy decisions, and she highly valued the resources available for continuing competence, practice guidance, and advocacy. Sue often mentions her use of the AOTA website to download consumer tip sheets for her clients and her use of the evidence-based practice resources when discussing the value of occupational therapy with external audiences, such as other program managers in the center and external stakeholders. As an incentive to join, Sue includes professional association memberships and participation in leadership as criteria for moving forward in career ladders. Sue is happy to learn that everyone on her staff joined both the state association as well as the AOTA. In return, Sue frequently points out opportunities for leadership that would fit well with individuals in her department and encourages them to apply. Believing that each member of her staff is a potential leader, Sue is not surprised to learn that four individuals have been elected or appointed to positions at the state and national association levels. Sue appreciates her team and how hard they work to support her and the department as a valued therapy service within the center. She gets to know her staff and pays attention so that she can personally recognize individuals for their contributions. She promotes supportive relationships at work so that others feel a sense of connection with coworkers, fostering accountability, engagement, and commitment to the team and to the center (Kouzes & Posner, 2017). Birthdays are celebrated once a month and recognition celebrations are frequent. As a busy manager and mother of 2 children, Sue knows that it is important to take care of herself so that she can continue to help others. She makes sure that she is eating healthy foods, exercising, getting enough sleep, and making time to have fun with family and friends. She takes time to regularly reflect on where she has been in her career and her professional goals for the future and thinks about how to develop others into leaders who can join her on her journey. Review Questions 1. 2. 3. When Sue involved her staff in problem solving and decision making around productivity standards, she was a. Directing b. Managing c. Controlling d. Leading Educating and engaging her department on the vision is a. Condescending b. Directing c. Inspiring d. Evaluating By encouraging her employees to join their state and national occupational therapy associations, Sue was influencing all the following except a. Professional responsibility b. Leadership c. Professional development d. Control Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 3. Leadership vs. Management: Differences and Skill Sets and are willing to take risks to generate small wins. Managers without a complementary leadership approach may be focused on the accomplishment of meaningless day-to-day tasks and do little to motivate employees to tackle difficult organizational challenges from external forces. The ability to lead is not based on position or title and can be developed by anyone at any time. It is important that employees think of themselves as leaders and set leadership development goals as part of their career trajectory. As current leaders retire in areas of administration, practice, academia, and research, the need is acute for emerging and established leaders to step into those positions to continue communicating occupational therapy’s strength as a viable and valuable health care discipline. Administrative and volunteer leaders have opportunities to develop leadership in themselves and in others through the leadership process. Identifying leadership capacities in others and inviting them to participate in leadership activities strengthens the collective leadership capacity of the profession. Choosing to be a leader begins with saying “yes” to leadership opportunities. Depending where you are on your leadership development trajectory, you may be willing to serve on a small organizational committee, work with others on developing documents that support departmental operations, or organize an interprofessional continuing education activity (e.g., journal club). Those who are ready to take on higher level leadership may seek out opportunities for employment as a health care administrator or manager, run for an elected position in their state or national professional association, or serve on a community board or committee that has a term requirement. Just as there will always be a need for health care, there will also always be a need for occupational therapy leaders who, through their actions and voices, can advocate for the profession and the clients and populations they serve. ❖ LEARNING ACTIVITIES 1. Reflect on the following questions: ■ What does leadership mean to you? ■ What is the difference between leadership and management? ■ What behaviors and actions have you taken when you were at your best as a leader? ■ Describe the behaviors of a person who you would consider your best leader. 2. Create a leadership trajectory. Draw a horizontal line across a sheet of paper. At the far left of that line, start a timeline of events in which you were a leader. On the top of the line, list the leadership activity and on the bottom of the line, list what was going on in your life professionally and personally. The middle of the line should depict where you are now in your leadership and personal life. As you expand your timeline to the right, start to plan your leadership development into the next 3–5 years. What types of activities will you engage and participate in? Reflect on the leadership skills you want to strengthen and the steps you will take to develop leadership capacities in others. 33 ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ ■ ■ ■ ■ B.5.2. Advocacy B.5.8. Supervision of Personnel B.7.2. Professional Engagement B.7.3. Promote Occupational Therapy B.7.5. Personal and Professional Responsibilities. For Additional Learning For additional information about concepts discussed in this chapter, see Chapter 1, “Theories of Leadership.” REFERENCES Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi .org/10.5014/ajot.2018.72S217 American Occupational Therapy Association. (2015). Standards for continuing competence. American Journal of Occupational Therapy, 69, 6913410055. https://doi.org/10.5014/ajot.2015 .696S16 American Occupational Therapy Association. (2017a). Continuing professional development in occupational therapy. American Journal of Occupational Therapy, 71, 7112410017. https://doi.org /10.5014/ajot.2017.716S13 American Occupational Therapy Association. (2017b). Vision 2025. American Journal of Occupational Therapy, 71, 7103420010. https://doi.org/10.5014/ajot.2017.713002 Arruda, W. (2016, November). 9 Differences between being a leader and a manager. Forbes. Retrieved from https://www.forbes.com /sites/williamarruda/2016/11/15/9-differences-between-being -a-leader-and-a-manager/#17a19f1f4609 Bârgău, M. (2015). Leadership versus management. Romanian Economic and Business Review, 10, 197–204. Retrieved from http://www.rebe.rau.ro/RePEc/rau/journl/SU15/REBE-SU15 -A16.pdf Carpenter, M., Bauer, T., & Erdogan, B. (n.d.). Principles of management. Retrieved from https://catalog.flatworldknowledge.com /bookhub/5?e=carpenter-ch01_s03#carpenter-chpr Cox, J. A. (2016). Leadership and management roles: Challenges and success strategies. AORN Journal, 104(2), 154–160. https://doi .org/10.1016/j.aorn.2016.06.008 Delmatoff, J., & Lazarus, I. R. (2014). The most effective leadership style for the new landscape of healthcare. Journal of Healthcare Management, 59, 245–249. https://doi.org/10.1097/00115514 -201407000-00003 Edwards, G., Schedlitzki, D., Turnbull, S., & Gill, R. (2015). Exploring power assumptions in the leadership and management debate. Leadership and Organization Development Journal, 36, 328–343. https://doi.org/10.1108/LODJ-02-2013-0015 Gousy, M., & Green, K. (2015). Developing a nurse-led clinic using transformational leadership. Nursing Standard, 29(30), 37–41. https://doi.org/10.7748/ns.29.30.37.e9481 Komives, S. R. (2013). Exploring leadership for college students who want to make a difference. San Francisco: Jossey-Bass. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 34 SECTION I. Foundations of Occupational Therapy Leadership and Management Kotterman, J. (2006). Leadership versus management: What’s the difference? Journal for Quality and Participation, 29(2), 13–17. Retrieved from https://search.proquest.com/openview/9e519b2d f53655fd0f5f39c35480c1ac/1?pq-origsite=gscholar&cbl=37083 Kouzes, J. M., & Posner, B. Z. (2017). The leadership challenge (6th ed.). Hoboken, NJ: John Wiley & Sons. Kruse, K. (2013, April). What is leadership? Forbes. Retrieved from https://www.forbes.com/sites/kevinkruse/2013/04/09/what-is -leadership/#5ea46e015b90 Lamb, A. J. (2016). The power of authenticity. American Journal of Occupational Therapy, 70, 7006130010. https://doi.org/10.5014 /ajot.2016.706002 Phipps, S. (2015). Transformational and visionary leadership in occupational therapy management and administration. OT Practice 20(15), CE1–CE7. Power. (n.d.). In Merriam-Webster’s online dictionary. Retrieved from https://www.merriam-webster.com/dictionary/power Rockwell, D. (2017, October). The truth about self kindness. Leadership Freak. Retrieved from https://leadershipfreak.blog/2017 /10/25/the-truth-about-self-kindness/ Rogers, P., Killian, C., Hudgins, E., & Pollard, T. (2016). Transitioning form clinician to manager. SIS Quarterly Practice Connections, 1(2), 17–19. Ross, S. (2014). A conceptual model for understanding the process of self-leadership development and action-steps to promote personal leadership development. Journal of Management Development, 33, 299–323. https://doi.org/10.1108/JMD-11-2012-0147 Solomon, I. G., Costea, C., & Nita, A. M. (2016). Leadership versus management in public organizations. Economics, Management and Financial Markets, 11(1), 143–151. Stoffel, V. C. (2014). Attitude, authenticity, and action: Building capacity. American Journal of Occupational Therapy, 68, 628–635. https://doi.org/10.5014/ajot.2014.686002 Surbhi, S. (2015, May 9). Difference between leadership and management. Key differences. Retrieved from https://keydifferences .com/difference-between-leadership-and-management.html Trastek, V. F., Hamilton, N. W., & Niles, E. E. (2014). Leadership models in health care—A case for servant leadership. Mayo Clinic Proceedings, 89, 374–381. https://doi.org/10.1016/j.mayocp .2013.10.012 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Evolution and Future of Occupational Therapy Service Delivery Anne M. Haskins, PhD, OTR/L, and Debra J. Hanson, PhD, OTR/L, FAOTA CHAPTER 4 LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ ■ Understand the evolution and funding sources of existing health care systems; Understand the influence of population needs, legislation, and scientific discovery on health care services development; Explore current trends in occupational therapy service delivery; Identify current population needs and implications for occupational therapy services; Explore future occupational therapy service delivery models; and Consider steps for influencing future public policy. KEY TERMS AND CONCEPTS • Baby Boomers • Interprofessional collaborative practice • Managed care • Millennials • Primary care • Private health insurance OVERVIEW H ealth care delivery in the United States is influenced by the dynamic interplay among societal needs, public health care policy, legislative and judicial decisions, scientific discovery, and the reimbursement structures underlying each context. In this chapter, we first consider the evolution of health care systems within the United States, the associated reimbursement structures, and changes to these systems and structures over time. We explore current trends in occupational therapy service delivery and reflect on their development. Consideration of population needs sets the stage for examining future opportunities for occupational therapy and associated service delivery models. The chapter concludes with some thoughts about steps for influencing future public policy. ESSENTIAL CONSIDERATIONS Evolving U.S. Health Care Systems: History of Health Care Organizations and Settings The history of the occupational therapy profession in the United States is closely aligned with the development of health • Reimbursement • Telehealth • Triple Aim care organizations. At the end of the 19th century, all health care was provided in the home. However, public health facilities were developed for the indigent population, in the form of local and state-run sanatoriums for individuals with chronic medical and mental health concerns (Wall, 2015). Over the course of the first 2 decades of the provision of occupational therapy services, a great deal of momentum was achieved in these settings; providers offered diversional, recuperative, and vocation-focused therapy appropriate for graded activity during a lengthy convalescence (Friedland & Silva, 2008). However, by 1919, approximately 123,000 soldiers with disabilities had returned to the United States after World War I, and the country was compelled to provide federally funded medical and rehabilitative services for these veterans (Gritzer & Arluke, 1985). A renewed sense of social responsibility developed as people became more aware of social problems. In particular, a growing number of individuals were injured in work accidents resulting from industrialization (Quiroga, 1995). By the 1920s, new scientific discoveries, as well as physician credentialing and regulation by the American Medical Association (AMA), were changing the hospital from a warehouse of care for the indigent to a place where modern and antiseptic Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.004 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 35 Evolution and Future of Occupational Therapy Service Delivery Anne M. Haskins, PhD, OTR/L, and Debra J. Hanson, PhD, OTR/L, FAOTA CHAPTER 4 LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ ■ Understand the evolution and funding sources of existing health care systems; Understand the influence of population needs, legislation, and scientific discovery on health care services development; Explore current trends in occupational therapy service delivery; Identify current population needs and implications for occupational therapy services; Explore future occupational therapy service delivery models; and Consider steps for influencing future public policy. KEY TERMS AND CONCEPTS • Baby Boomers • Interprofessional collaborative practice • Managed care • Millennials • Primary care • Private health insurance OVERVIEW H ealth care delivery in the United States is influenced by the dynamic interplay among societal needs, public health care policy, legislative and judicial decisions, scientific discovery, and the reimbursement structures underlying each context. In this chapter, we first consider the evolution of health care systems within the United States, the associated reimbursement structures, and changes to these systems and structures over time. We explore current trends in occupational therapy service delivery and reflect on their development. Consideration of population needs sets the stage for examining future opportunities for occupational therapy and associated service delivery models. The chapter concludes with some thoughts about steps for influencing future public policy. ESSENTIAL CONSIDERATIONS Evolving U.S. Health Care Systems: History of Health Care Organizations and Settings The history of the occupational therapy profession in the United States is closely aligned with the development of health • Reimbursement • Telehealth • Triple Aim care organizations. At the end of the 19th century, all health care was provided in the home. However, public health facilities were developed for the indigent population, in the form of local and state-run sanatoriums for individuals with chronic medical and mental health concerns (Wall, 2015). Over the course of the first 2 decades of the provision of occupational therapy services, a great deal of momentum was achieved in these settings; providers offered diversional, recuperative, and vocation-focused therapy appropriate for graded activity during a lengthy convalescence (Friedland & Silva, 2008). However, by 1919, approximately 123,000 soldiers with disabilities had returned to the United States after World War I, and the country was compelled to provide federally funded medical and rehabilitative services for these veterans (Gritzer & Arluke, 1985). A renewed sense of social responsibility developed as people became more aware of social problems. In particular, a growing number of individuals were injured in work accidents resulting from industrialization (Quiroga, 1995). By the 1920s, new scientific discoveries, as well as physician credentialing and regulation by the American Medical Association (AMA), were changing the hospital from a warehouse of care for the indigent to a place where modern and antiseptic Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.004 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 35 36 SECTION I. Foundations of Occupational Therapy Leadership and Management surgical and medical procedures were available and recovery and cure could be achieved (Wall, 2015). Although hospitals were clearly the way of the future, by 1938 only 13% of hospitals approved by the AMA had qualified occupational therapy practitioners on their staffs; the majority of practitioners were still employed in mental institutions, tuberculosis sanatoriums, and penal institutions (Andersen & Reed, 2017). World War II ushered in the rehabilitation movement, and as a result, rehabilitation departments were developed, first within the veterans’ hospitals and then as nonprofit and for-profit entities. Medical advances made during the war, such as the invention of antibiotics, allowed more soldiers to survive, but their physical handicaps hampered their return to independent living. Therefore, occupational therapy shifted attention from providing diversional, recuperative, and vocational-focused therapy to ADLs and other areas that promote client independence (Andersen & Reed, 2017). At the same time, diseases common in the United States before the war, such as tuberculosis and polio, were eliminated through scientific discoveries; subsequently, many sanatoriums that had been built for individuals with those conditions were closed. As doors closed for occupational therapy involvement in sanatoriums, legislation opened the door for occupational therapy involvement in hospital settings. The Vocational Rehabilitation Act Amendments of 1943 (P. L. 78–113; formally, the Barden–LaFollette Act) provided funds for physical restoration services as part of vocational rehabilitation programs (Gritzer & Arluke, 1985), and the Hospital Survey and Construction Act of 1946 authorized federal grants to states for construction and modernization of hospitals throughout the United States (Wall, 2015). These initiatives coincided with Franklin D. Roosevelt’s introduction of the Economic Bill of Rights in 1944; he affirmed in his State of the Union address (Roosevelt, 1944) the right of every American to achieve and enjoy good health, thereby setting the stage for the growth of nonprofit and for-profit health care organizations (Andersen & Reed, 2017). Charity and community hospitals were formed first, but others were established as population needs expanded. Coinciding with advances in medicine, demographic shifts, and changing family structures, geriatric care was introduced in the 1950s, and it was expanded with support from legislation related to Medicare. Care in the United States is currently delivered through federal, state, and private institutions. Examples are presented in Table 4.1. Reimbursement for Health Care Reimbursement is payment for medical or health care services (Vennes, 2009) and an essential component of the continued existence of any health care organization. The U.S. reimbursement system comprises private health insurance and federally funded health insurance programs, including Medicare (Medicare Law of 1965), Medicaid (established with Medicare), the Children’s Health Insurance Program (CHIP; established by the Balanced Budget Act of 1997), and coverage for military personnel (Barnett & Berchick, 2017; TABLE 4.1. Types of Health Care Organizations TYPE OF ORGANIZATION GENERAL DESCRIPTION Federal government ■ Hospitals serving disabled veterans ■ Hospitals serving Armed Forces and Coast Guard ■ Indian Health Service ■ Public Health Service hospitals and clinics (including leprosarium) ■ Medical facilities associated with prisons State government ■ Infirmaries associated with prisons and reformatories ■ Hospitals for people with mental illness ■ State medical school hospitals and clinics Local government ■ City hospitals and clinics ■ County hospitals and public health clinics Nonprofit organization ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ For-profit organization ■ Facilities owned by individuals or groups for the care of their own patients or clients ■ Investor-owned facilities (e.g., hospitals, laboratories, nursing homes, surgical centers, rehabilitation facilities, home health facilities, HMOs, PPOs, hospices), including corporations and management corporations ■ Walk-in medical clinics Charity hospitals Community hospitals HMOs Home health facilities Hospices Industrial hospitals and clinics PPOs Private teaching hospitals Specialty hospitals Surgical centers Wellness centers Note. HMOs = health maintenance organizations; PPOs = preferred provider organizations. Source. From K. Jacobs, 2011, “Evolution of occupational therapy delivery systems,” in K. Jacobs & G. L. McCormack (Eds.), The Occupational Therapy Manager (5th ed., p. 41), Bethesda, MD: AOTA Press. Copyright © 2011 by AOTA Press. Used with permission. U.S. Department of Health and Human Services [DHHS], n.d.). The viability of occupational therapy as a health care service is dependent on availability of reimbursement sources and reimbursement eligibility. Private health insurance Private health insurance, also referred to as commercial plans, is purchased by employers or by individuals (Barnett & Berchick, 2017) and, although it is identified as “private,” it is affected by federal subsidies (to offset costs and make insurance more affordable to people with lower incomes) and policy (Congressional Budget Office [CBO], n.d.). The cost of Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 4. Evolution and Future of Occupational Therapy Service Delivery private health insurance continues to rise. Though the rise of premiums has slowed in recent years, recent orders by the U.S. administration may affect the cost of private health insurance (CBO, n.d.). In October 2017, President Donald Trump signed an executive order to remove the payment of federal subsidies to private insurance companies (White House, 2017); the actual influence of this order on cost and care remains unknown. Coverage offered by employers or purchased by individuals is highly variable in regard to premiums paid. In general, higher premiums result in broader coverage, whereas lower premiums result in less coverage and more out-of-pocket expenses. Federally funded health insurance Federally supported health insurance programs are prominent in the United States. Supported programs include Medicare, Medicaid, CHIP, and coverage for active duty and veteran military members and their families. Medicare, Medicaid, and CHIP. Medicare, Medicaid, and CHIP coverage is for specific populations. Medicare is designed to provide insurance coverage for people ages 65 years or older and, in some cases, those younger than 65 with specified diagnoses (Centers for Medicare and Medicaid Services [CMS], 2014, 2017a). Medicaid is a federally and state funded program for people with low incomes, women who are pregnant, and populations with long-term health care needs (CMS, 2017a). CHIP originated from the Balanced Budget Act of 1997 and is a federally and state-funded program designed to supplement families who do not meet the criteria for Medicaid but require health care reimbursement assistance (CMS, n.d.-b, 2017a). Table 4.2 gives an overview of each of the aforementioned programs and the populations served. Military coverage. Globally, there are 19 million U.S. military veterans (Holder, 2016) and 1.3 million active duty servicemen and servicewomen in the U.S. military (U.S. Department of Defense [DoD], 2015). Active-duty service 37 members’ families account for an additional 1.8 million people (DoD, 2015). Insurance coverage is also available for military personnel, veterans, and their families. TRICARE coverage is available for active-duty personnel, retiree (CMS, n.d.-b); and personnel of the Civilian Health and Medical Program of the Department of Veterans Affairs and the veterans health program (CMS, n.d.-b). Varying coverage plans are available within each of these insurance options. Insurance Coverage Overall In 2016, private health care insurance covered 67.5% of the population, whereas federally funded coverage insured 37.3% of the population (Barnett & Berchick, 2017). Employer-paid insurance provided coverage for 55.7% of the population, whereas Medicaid and Medicare provided coverage for 19.4% and 16.7%, respectively (Barnett & Berchick, 2017). Direct-purchase coverage was assumed by 16.2% of the population, and military personnel represented 4.6% of the population (Barnett & Berchick, 2017). In 2016, as many as 28.1 million Americans (8.8% of the population) remained uninsured (Barnett & Berchick, 2017), although the number of insured Americans has grown substantially as a result of health care reform legislation. Managed Care Managed care represents health care delivery systems that began with implementation of the Health Maintenance Organization Act of 1973 (P. L. 93–222) and was intended to improve quality and accessibility as well as streamline care, thereby controlling costs (Social Security Administration, n.d.). Four types of managed care insurance plans are available: 1. 2. 3. 4. Exclusive provider organizations, Health maintenance organizations (HMOs), Preferred provider organizations (PPOs), and Point of service (POS) plans (CMS, n.d.-c, n.d.-d; U.S. National Library of Medicine [NLM], n.d.). TABLE 4.2. Medicare, Medicaid, and CHIP Overview INSURANCE TYPE POPULATIONS Medicare ■ Part A: Inpatient hospital short-term skilled nursing facility coverage; funded by payroll taxes. (CMS, 2014, 2017a) ■ Part B: Supplemental insurance that covers doctor’s visits, occupational therapy, other rehabilitation services, home health, and necessary medical equipment; individual pays a monthly premium (CMS, 2014, 2017a) Individuals age 65 years or older, younger than 65 with specific diagnoses, and/or in end-stage renal disease (CMS, 2014, 2017a) Medicaid ■ Federal- and state-funded program Individuals with low incomes, pregnant women, people with disabilities, those who need long-term care (CMS, 2017a). CHIP ■ Federal- and state-funded program Children whose families do not qualify for Medicaid services (CMS, n.d.-b, 2017a) Note. CHIP = Children’s Health Insurance Program; CMS = Centers for Medicare and Medicaid Services. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 38 SECTION I. Foundations of Occupational Therapy Leadership and Management Each type of plan is intended to reduce health care costs (CMS, n.d.-d) through the use of networks. Exclusive provider organizations require that individuals see only specific health care professionals in a specified network to receive coverage (CMS, n.d.-c). In HMOs, the individual is assigned to a primary care physician who is responsible for care coordination (i.e., the client needs a referral to access other services; CMS, n.d.-d; NLM, n.d.). Individuals covered through PPOs have lower copays, and health care services are reimbursed at a higher rate if they remain inside the predetermined network as opposed to seeking care outside of the network (NLM, n.d.). In POS plans, the individual selects either an HMO or PPO for each episode of care (NLM, n.d.). In 2016, managed care plans accounted for 30.6% of Medicare plans, 62.7% of Medicaid plans, 100% of military plans, and 99.1% of private plans (MCOL, n.d.). including military veterans, people with disabilities, elderly people, children, and others. In some instances, legislation addressed occupational therapy services and provided support for specific occupational needs, including supported employment, education, and assistive device coverage (Andersen & Reed, 2017). However, legislation also curtailed occupational therapy involvement in some practice areas. For example, the Social Security Amendments of 1965 initially included occupational therapy as a covered service, but later it was interpreted to require a physician order for occupational therapy services. A sample of the legislative influence on occupational therapy services is provided in Table 4.3. The table shows that legislation has had (and continues to have) a strong role in determining which populations are served by occupational therapy, where the services are provided, and how those services are reimbursed (Exhibit 4.1). Continued Influence of Legislation on Health Care Policy Legislative Influence on Health Care Services Evolution Several legislative measures have been instituted since the 1940s that influenced the availability of reimbursement for health care services to population groups in the United States, In 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act (ACA), which took effect in 2014. The intent of the ACA was to provide health care coverage to those who were uninsured (Braveman & TABLE 4.3. Legislation Influence on Service Provision LEGISLATION AND JUDICIAL DECISIONS YEAR ENACTED INFLUENCE ON HEALTH CARE, POPULATIONS, AND OCCUPATIONAL THERAPY Social Security Act—Additional of Title 18: Medicare 1965 Provision of care for those age 65 years or older. Initially included occupational therapy as covered as part of usual services; later interpreted occupational therapy to require a physician order (Andersen & Reed, 2017). Health Maintenance Organization Act 1973 Established HMOs to manage care and control costs (Andersen & Reed, 2017). Education for All Handicapped Children 1975 ■ Enhanced occupational therapy provision in schools ■ Established IEPs (Jackson, 2007). Omnibus Reconciliation Act of 1980 1980 Occupational therapy coverage in rehabilitation and as stand-alone service in home health (AOTA, n.d.). Omnibus Reconciliation Act of 1981 1981 Occupational therapy was no longer considered a stand-alone service for home health (AOTA, n.d.). Children’s Health Insurance Program (Balanced Budget Act of 1997) 1997 Provided coverage for children whose families were eligible for Medicaid services (Andersen & Reed, 2017). Balanced Budget Act 1997 ■ Emphasized controlling health care costs through prospective payment systems ■ Capped Medicare payments to occupational therapy in rehabilitation, outpatient, and skilled nursing facilities (Andersen & Reed, 2017). 2009, 2015 ■ Reauthorized the Children’s Health Insurance Program (Centers for Medicare and Medicaid Services, n.d.-a) ■ 6-year extension in 2017 (Kaiser Family Foundation, 2018). 2017 ■ Repealed the individual mandate for individual health insurance. ■ Medicare Part B occupational therapy $2,010.00 reimbursement cap that first accompanied the Balanced Budget Act of 1997 was reinstituted as Congress did not extend the exception policy (Parsons, 2018). Children’s Health Insurance Program Reauthorization Act Tax Reconciliation Act Note. AOTA = American Occupational Therapy Association; HMOs = health maintenance organizations; IEPs = individualized education programs. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 4. Evolution and Future of Occupational Therapy Service Delivery 39 EXHIBIT 4.1. Policy Learning Activity Using available textbooks, databases, search engines, and the American Occupational Therapy Association (AOTA) website section “Advocacy and Policy” (http://www.aota.org/Advocacy-Policy.aspx), search for and review the legislative and judicial outcomes in the table below and identify their influence on health care, populations, and occupational therapy service provision. LEGISLATION AND JUDICIAL DECISIONS YEAR ENACTED Comprehensive Outpatient Rehabilitation Facilities Regulations (CMS, 2013) 1982 Tax Equity and Fiscal Responsibility Act of 1982 1982 Social Security Amendments of 1983 1983 Developmental Disabilities Act of 1984 1984 Education of the Handicapped Act Amendments of 1986 1986 Americans with Disabilities Act 1990 Individuals with Disabilities Education Act (IDEA) of 1990 1990 Human Services Amendments of 1994 (Head Start was reauthorized) 1994 Health Insurance Portability and Accountability Act of 1996 1996 Individuals with Disabilities Education Act Amendments of 1997 1997 Olmstead v. L.C. 1999 Individuals with Disabilities Education Improvement Act of 2004 2004 Patient Protection and Affordable Care Act 2010 INFLUENCE ON HEALTH CARE, POPULATIONS, AND OCCUPATIONAL THERAPY Go to the “Advocacy and Policy” Section of the AOTA website and select “Congressional Affairs”. What legislation issues are currently influencing occupational therapy practice? Metzler, 2012), including individuals with preexisting conditions; expand coverage for those with limited coverage; improve overall health care system delivery; enhance communication and collaboration between providers; fund public health and other prevention programs; and ease the financial burden on existing private and federal insuring bodies (Braveman & Metzler, 2012; Fisher & Friesema, 2013; Moyers & Metzler, 2014). Despite the increase in coverage for approximately 23 million Americans (Dickman et al., 2017), the ACA has been met with substantial opposition from varying political and religious bodies, which have challenged the law on issues ranging from states’ rights to its original mandate of contraceptive coverage (Hall, 2016). “We have not seen federal law fought so fiercely since the Civil Rights era” (Hall, 2016, p. 576), and the ACA’s opposition in the judicial arena has already influenced health care (see Exhibit 4.2). Ultimately, the outcomes of the ACA on health care, including occupational therapy, are still relatively unknown given the newness of the act and passage of a recent tax reform bill. The Tax Reconciliation Act of 2017 (P. L. 115–97) included a provision to eliminate the mandate for individuals to buy health insurance. It is expected that this provision will result in approximately 4 million fewer people purchasing EXHIBIT 4.2. How the Judicial Branch Can Affect Health Care Although numerous lawsuits have been filed in opposition to the ACA, one has substantial influence over the original intent of the ACA. National Federation of Independent Businesses (NFIB) v. Sebelius (2012) was a Supreme Court case in which 24 states and additional private businesses challenged the constitutionality of the ACA to require states’ Medicaid expansion (Hall, 2016). The Supreme Court ruled that states could opt out of expanding Medicaid coverage. This ruling likely dealt a substantial blow to the potential success of the ACA; in 2016, only 31 states had expanded Medicaid programming (Hall, 2016). Research regarding the outcomes of the ACA has shown that coverage gains for the uninsured were greater in states with Medicaid expansion than in those without expansion (Buchmueller et al., 2016). In NFIB v. Sebelius, the Supreme Court also ruled that individuals would not be mandated by law to secure insurance but would be penalized for being uninsured in the form of a federal tax (Hall, 2016). Ultimately, the outcome of NFIB v. Sebelius was lesser coverage options through Medicaid in 29 states and individuals opting out of coverage (Hall, 2016). Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 40 SECTION I. Foundations of Occupational Therapy Leadership and Management health insurance in 2019 and 13 million fewer people by 2027, which in turn will influence the federal subsidies to private insurers and Medicaid (CBO, 2017). evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs” (p. 613). Despite the provisions in the ACA to build preventive public health programming and address the needs of underinsured or uninsured populations as well as societal needs, occupational therapy continues to serve in traditional medical settings in a reactive, rather than revolutionary, type of service delivery in emerging settings. The primary settings in which practitioners are employed are long-term care/skilled nursing facilities (55.9% OTAs/19.2% OTs) and hospitals (11.4% OTAs/26.6% OTs), followed by pediatric settings (AOTA, 2015). The smallest areas of practice are community settings, which account for 1.7% of OTAs and 2% of OTs, followed by mental health settings, in which 1.4% of OTAs and 2.4% of OTs are employed (AOTA, 2015). Figure 4.1 shows practitioner employment by setting. As reported in the 2015 Salary and Workforce Survey (AOTA, 2015), 3 work settings accounted for the majority (68.7%) of occupational therapy practice: hospital (non– mental health), schools, and long-term care (LTC)/skilled nursing facility (SNF). Those working in the hospital (non– mental health) were identified as least likely to have changed jobs within the last 2 years (83.6%), closely followed by a low turnover rate for individuals working in schools (83.1%), and LTC/SNF settings (73.9%; AOTA, 2015). Review Questions 1. What relationships do you notice between population needs and legislative actions in past history? 2. Which type of insurance (private or federally funded) represents the majority of the insurance coverage used by the U.S. population? What influence might insurance coverage have on client access to occupational therapy services? 3. What are the primary differences in the 4 types of managed care plans, and how might the differences in plans affect patient access to health care services? PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Current Trends in Occupational Therapy Service Delivery The American Occupational Therapy Association’s (AOTA’s; 2007) Centennial Vision reads “[w]e envision that occupational therapy is a powerful, widely recognized, science-driven, and FIGURE 4.1. Occupational therapy employment by setting. Academia 1.5% Community 1.7% 2% OTAs 6.1% OTs 2.8% 4.6% Early Intervention Free-Standing Outpatient 5.39% Home Health 4.3% 6.8% 10.7% 11.4% Hospital 26.6% 55.9% LTC/SNFs 19.2% 1.4% 2.4% Mental Health .9% 1.5% Other 15% Schools 0 10% 19.9% 20% 30% 40% 50% 60% Source. From 2015 AOTA Salary & Workforce Survey by the American Occupational Therapy Association, 2015, p. 4, Bethesda MD: AOTA Press. Copyright © 2015 by the American Occupational Therapy Association. Reprinted with permission. Note. LTC = long-term care; OTA = occupational therapy assistant; OT = occupational therapists; SNF = skilled nursing facility. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 4. Evolution and Future of Occupational Therapy Service Delivery These findings suggest that there is a low likelihood that occupational therapy practitioners with the requisite skills would be drawn to explore work in emerging practice areas. However, for those practitioners who did change jobs in 2014, the opportunity to work in a more desirable or more flexible employment setting was most commonly identified as the reason for change (41.8%); it was cited more often than salary and benefits (26.8%), and family or personal reasons (25.6%). Moreover, for the 9.2% of respondents who indicated that they were considering or planning to leave the profession, 19.2% indicated that they desired to work in a different field, and 22% expressed dissatisfaction with the profession (AOTA, 2015). These data suggest that a small but growing percentage of the profession is poised to explore alternative practice areas. More than a decade ago, the AOTA Board of Directors identified a misalignment between the profession and the external environment as forming a barrier to the profession’s Centennial Vision (AOTA, 2007). Simply, the profession’s priorities were not congruent with the needs of society. Although there is a need for occupational therapy practitioners to serve individuals in traditional settings, practitioners must grow in their knowledge of other paths to serving the nation’s needs (AOTA, 2007). In 2011, AOTA identified emerging niche areas for occupational therapy within the areas of children and youth, health and wellness, mental health, productive aging, rehabilitation, disability and participation, work and industry, and education (Yamkovenko, n.d.) and comprise subtopics that reflect present and anticipated societal needs (see Table 4.4). The Healthy People Initiative (DHHS, 2017) provides further guidance for areas of focus for occupational therapy. Initiatives essential to support health outlined in the Healthy People 2020 report include (1) access to health services; (2) clinical preventive services; (3) environmental quality; (4) injury and violence; (5) maternal, infant, and child health; 41 (6) mental health; (7) nutrition, physical activity, and obesity; (8) oral health; (9) reproductive and sexual health; (10) social determinants; (11) substance abuse; and (12) tobacco use. Population needs With a population of more than 327 million people, the United States was the 3rd most populated country in the world in 2018 (U.S. Census Bureau, 2018b), with an ever-growing diversity in race, ethnicity, and age (U.S. Census Bureau, 2017). In 2017, non-Hispanic White people continued to comprise the majority of the population in the United States, and cumulatively, minority populations represented slightly more than one-third of the population (U.S. Census Bureau, 2012). Population growth is expected to slow nationally and reach approximately 400 million by 2051 (U.S. Census Bureau, 2015b). Population projections indicate that by 2060, minority populations will represent 56% of the total population (U.S. Census Bureau, 2015b). For occupational therapy, population diversity represents a need for practitioners who are culturally sensitive and prepared to serve people with varying “customs, beliefs, activity patterns, behavioral standards, and expectations” (AOTA, 2014b, p. S9). Two generations are particularly important when considering occupational therapy service delivery: (1) Baby Boomers and (2) Millennials. The population of the United States is significantly older than it was at the turn of the last century (U.S. Census Bureau, 2017). Baby Boomers, people born between 1946 and 1964, account for 75.4 million people (U.S. Census Bureau, 2015a) of the U.S. population, and those ages 65 years or older are expected to account for 19% of the population by 2030 (Vincent & Velkoff, 2010). The aging of this population accounted for an increase of 14.2 million people ages 65 years or older between 2000 and 2016 (U.S. Census Bureau, 2017). When all Baby Boomers reach the age of 65 years in 2030, they will account for 1 in 7 people in the United States (U.S. Census Bureau, 2015b). The growth of the TABLE 4.4. Emerging Niche Practice Areas BROAD PRACTICE AREA AREA OF NEED Children and youth Broader scope in schools, bullying, childhood obesity, driving for teens, transitions for older youth Education Distance learning, reentry to the profession Health and wellness Chronic disease management, obesity, prevention Mental health Depression, recovery, peer support model, sensory approaches to mental health, veterans’ and wounded warriors’ mental health Productive aging Aging in place and home modifications, low vision, community mobility, and older drivers Rehabilitation, disability, and participation Autism in adults, cancer care and oncology, hand transplants and bionic limbs, new technology for rehabilitation, telehealth, veteran and wounded warrior care Work and industry Aging workforce, new technology at work Source. Data are from Yamkovenko, n.d. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 42 SECTION I. Foundations of Occupational Therapy Leadership and Management population ages 65 or older has significant ramifications for the U.S. health care system, because the incidence of disease and disability increases with age. Millennials, those born between 1982 and 2000, now represent more than 25% of the U.S. population; 44.2% of the 83.1 million millennials are part of an ethnic or racial minority population (U.S. Census Bureau, 2015a). The millennial generation is larger and more complex in terms of other demographic characteristics than the Baby Boomer generation, and occupational therapy as a profession must consider Millennials’ present and future influence on society, the workforce, and the health care system. Among the plethora of variables that influence health and health care delivery in the United States, arguably the most influential is socioeconomic status. In 2016, the median income per household in the United States was $59,039 (Semega et al., 2017). In 2016, women earned $41,554 on average compared to earnings of $51,640 for men (Semega et al., 2017). Although median income per household has grown in recent years, approximately 12.7% (40.6 million people) of the U.S. population falls below the national poverty level (Semega et al., 2017). The poverty threshold in the United States was $24,858 for a household of 2 adults and 2 children (U.S. Census Bureau, 2018a). About 14.0% of those living in poverty are women ages 18–64 years, and 32.6% are children (Semega et al., 2017). Population implications for occupational therapy services Of the priorities identified within the AOTA emerging niches and the Healthy People’s 2020 initiative, several are reflected as needs in occupational therapy literature: ■ Access to care (AOTA, 2017b), ■ Mental health and substance abuse disorder services (Braveman & Metzler, 2012), and ■ Prevention and wellness (Braveman & Metzler, 2012; Hildenbrand & Lamb, 2013). Access to care. Vision 2025 (AOTA, 2017b) outlined 5 guidelines for care. One is that services must be accessible, that is, individualized and culturally sensitive. Culturally sensitive care requires moving beyond basic notions of race and ethnicity to seeking understanding of each individual’s socioeconomic status, values, family, beliefs, and needs (AOTA, 2014a) and accepting that those characteristics are fundamental to designing appropriate care (see Wells et al., 2016, for more on culturally sensitive care). Accessibility is particularly important to addressing the significant health disparities in the United States that are largely attributed to economic inequality. Buchmueller et al. (2016) reported improved coverage for Hispanic, Black, and White populations as a result of the ACA, but they noted that significant disparities continue with regard to race, ethnicity, and health care. Dickman et al. (2017) found that wealthy Americans now outlive poor Americans by 10–15 years, largely because poor Americans have limited access to health care services, a result of lack of insurance and the high cost of care. Mental health and substance abuse. Perceived psy- chological stress is now recognized nationally as a determinant of overall health and wellness. The results of a recent survey series conducted by the American Psychological Association (APA; n.d.) revealed “the serious physical and emotional implications of stress and the inextricable link between the mind and body” (para 1). Occupational therapy practitioners must build programming to address this epidemic across existing practice settings and in the public health arena. Special emphasis should be placed on addressing the mental health needs of Millennials who have been found not only to have significantly higher rates of anxiety than the Baby Boomer population but also exercise fewer active coping strategies (Brown et al., 2017). Individuals who are uninsured have been reported to experience higher psychological stress than do those with insurance (APA, 2018), and occupational therapy practitioners should identify avenues addressing the health needs of this population. Occupational therapy has deep roots in working with veterans and must continue service in traditional capacities of working with veterans who have experienced physical or psychological trauma and are seeking to gain independence in occupations and reintegrate into their families and communities. Occupational therapy practitioners must also continue to build services to address the mental health needs of veterans, with an emphasis on posttraumatic stress disorder and suicide. It has been estimated that 20 veterans die each day from suicide (U.S. Department of Veterans Affairs, 2016). Occupational therapy practitioners must begin to explore their role in suicide prevention, advocacy, and intervention (Kashiwa et al., 2017). The occupational therapy profession must also address the mental health needs of forcibly displaced refugees and human trafficking survivors. At the conclusion of 2015, an estimated 65.3 million people had been displaced forcibly worldwide; 51% of those displaced were children (United Nations High Commissioner for Refugees, 2015). Refugees experience a plethora of traumatic events ranging from lack of basic necessities and emotional security to violence and, subsequently, experience high frequency of mental health issues (Abou-Saleh & Christodoulou, 2016). When people become refugees, every aspect of their life is completely upended. Similarly, the World Health Organization (WHO; 2012; WHO, Regional Office for Europe, 2014) has recognized human trafficking as a public health crisis and has called for a multidisciplinary approach to provide interventions for survivors and to identify the victims. Occupational therapy practitioners can work with refugees and survivors to develop healthy active coping skills, build new habits and routines in novel environments, and cultivate skills that contribute to individuals’ abilities to engage in satisfying occupations. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 4. Evolution and Future of Occupational Therapy Service Delivery In 2017, a total of 16 natural disasters in the United States resulted in an estimated cost of $306 billion, 362 deaths, and the displacement of residents in the areas affected (National Oceanic and Atmospheric Administration, 2018). Nursing literature demonstrates that the nursing professions’ involvement in environmental disaster response stretches back for decades (Polivka & Chaudry, 2018). AOTA (2017a) has asserted that “occupational therapy, too, has a role in disaster response and risk reduction” (para. 1). AOTA identified occupational therapy practitioners’ skill at evaluation and intervention of and for mental health needs during “disruption in life routines” (para. 4) and ability to address other longterm needs that influence individuals’ ability to engage in occupations. Opioid abuse has reached epidemic proportions in the United States and has been declared a public health emergency (Salama, 2017). Opioids include both prescription and illegal drugs such as oxycodone, fentanyl, hydrocodone, morphine, and heroin (National Institute on Drug Abuse, 2017). Opioid overdose deaths increased 200% in the past 17 years, with significant increases in men and women, people of all races, and those between the ages of 25 and 44 years and ages 55 years or older, especially in the Midwest, South, and Northeast regions of the United States (Rudd et al., 2016). The occupational therapy profession must begin to prepare practitioners to address the needs of individuals with substance abuse and addiction issues, with a focus on development of life skills. Prevention and wellness. A key need in this area for the Baby Boomer population is safety and fall prevention (AOTA, 2014c; Mackenzie et al., 2013). Falls are the leading cause of accidental injury or death among the older population (Mackenzie et al., 2013). Fall hospitalization rates are increasing, and fiscal projections allot more than $100 million for fall-related accidents (Mackenzie et al., 2013). Instead of waiting for elderly patients to fall and sustain hip fractures, occupational therapy practitioners could complete a physical assessment and a home evaluation to eliminate hazards contributing to falls (AOTA, 2014c; Metzler et al., 2012; Muir, 2012). Future Occupational Therapy Service Models Occupational therapy in primary care: Prevention, wellness, and chronic disease management The Triple Aim of the ACA (2010) is to increase efficiency in health care delivery, increase effectiveness to the population, and improve the patient experience. The goal is to reduce readmission rates, increase patient satisfaction, and lower overall health care costs. Initiatives are specifically aimed at the 133 million Americans with 1 or more chronic conditions that account for more than 75% of health care costs (AOTA, 2014c). In many of these situations, management of 2 or more chronic conditions is required. For example, the individual 43 managing diabetes might be obese, with associated high blood pressure and chronic heart failure. Primary care is defined as “[t]he provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (Metzler et al., 2012, p. 266). There is tremendous opportunity for occupational therapy practitioners working in primary care to address health promotion and lifestyle modification, including mental and behavioral health management (AOTA, 2014b; Posmontier & Breiter, 2012). For example, practitioners might assist the client to create routines to support health, including medication management, blood sugar checks, healthy eating, and physical and social activity. To achieve integration into the primary care setting, reimbursement challenges must be navigated successfully (Hildenbrand & Lamb, 2013; Mackenzie et al., 2013; Metzler et al., 2012; Muir, 2012). Currently, public funds, such as the Prevention and Public Health Trust Fund, and Community Transformation Grants, have opened doors for occupational therapy services (Hildenbrand & Lamb, 2013), and options for occupational therapy reimbursement have been explored within the chronic care model, Medicaid health homes, CMS comprehensive primary care, and Federally Qualified Health Centers, and other health care service delivery models (AOTA, 2013; Goldberg & Dugan, 2013). However, consistent funding will be dependent on legislative developments related to the ACA and other health care measures (AOTA, 2014c; Hildebrand & Lamb, 2013). Models for cost containment The United States spends more on health care than any other industrialized country in the world (Schneider et al., 2017). National health expenditures reached $3.2 trillion (17.8% of the GDP) in 2015 (Dieleman et al., 2017) and are projected to represent 19.9% of the GDP by 2025 (CMS, 2017b). Despite the amount of money spent on health care, the United States ranked last in health care access, equity, and outcomes when compared with 10 other high-income countries (Schneider et al., 2017). The poor ranking of the U.S. health care system internationally is a result of numerous factors, including limited access to care, inequality in the health care system, and prevalence of chronic conditions. Cost containment in occupational therapy will include increased use of OTAs to extend the services provided by occupational therapy (Johnson, 2013). Successful collaboration between OTs and OTAs can maximize use of labor options (AOTA, 2014a). The consumer is able to obtain services at a reduced cost without reduction in quality, assuming appropriate therapist supervision. In addition, therapists’ time is released to pursue such areas as program development, research, and administration. Incorporation of a data-driven management process is essential to reduce costs, improve outcomes, and highlight the unique value of occupational therapy services (Hitchon, 2014). Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 44 SECTION I. Foundations of Occupational Therapy Leadership and Management This requires integration of quality measures into the occupational therapy practice process, with consideration to proactive measures such as fall prevention (Leland et al., 2012). Interprofessional collaborative practice and community partnership service models The complexities of the health care system and the people it serves mandates interprofessional collaboration in service delivery. Interprofessional collaborative practice happens“[w]hen multiple health workers from different professional backgrounds work together with patients, families, [careers], and communities to deliver the highest quality of care” (WHO, 2010, p. 7). Interprofessional health care has been emphasized as a need by the WHO since 1977, because lack of interprofessional care is a leading cause of patient deaths in the United States (Sternberg, 2016). In addition to collaboration within medical settings, occupational therapy practitioners must seek to build collaborative relationships with other professionals and community members to meet the dynamic and complex needs of the public. As an example, AARP (2015) describes the description of the role of occupational therapy in enhancing home fit is described by AARP (2015). Other examples of partner organizations to enhance driving and community mobility are described in the “Practice” section of the AOTA website under the heading “Productive Aging” (http://www.aota.org /Practice/Productive-Aging.aspx). Scientific Discovery, Information Management, and Technology Throughout history, scientific discovery and technology have played a major role in health care delivery. Occupational therapy practitioners are inundated with new options for practice, ranging from provision of client care following ever-­ changing and improving medical procedures, smartphone technologies for intervention, and virtual reality rehabilitation to expansion in state-of-the-art prosthetics. Telehealth, an emerging service model associated with technology development, includes “the application of evaluative, consultative, preventive, and therapeutic services delivered through telecommunication and information technologies” (AOTA, 2013, p. S69). Through telehealth, occupational therapy practitioners are able to direct occupational therapy services, provide consultation, and coordinate home transitions for clients (Cason & Jacobs, 2014). Reimbursement for occupational therapy telehealth services has been approved in numerous states (Center for Connected Health Policy, 2018). Technology also makes possible immediate access to clients’ electronic health care records, more than 24 million articles on PubMed, and countless resources through the AOTA website. For occupational therapy practitioners, vigilance in evaluating the worth of new intervention technologies and competence in prescribing those interventions are imperative. Equally essential is the practitioner’s ability to simply manage the flow of information that informs practice. Ultimately, occupational therapy practitioners must become adept at information management. Academic and continuing education programs must build opportunities for students and practitioners to build these skills to allow them to navigate the complexities of occupational therapy practice in the 21st century. Public Policy’s Ongoing Influence Public policy has shaped delivery of health care in the United States and will continue to influence service delivery. Occupational therapy practitioners must take the initiative to both understand and advocate for legislation that is beneficial to population needs and to the profession. The legislation, including the ACA (Yuen et al., 2017), is so complex that it can be difficult to follow and understand, but doing so is central to developing reimbursable programs. In addition to building and maintaining an awareness of current societal trends, occupational therapy practitioners can benefit from national resources and organizational groups such as the American Occupational Therapy Political Action Committee, which advances occupational therapy services through federal legislative measures and informs practitioners of measures influencing practice. However it is accomplished, it is essential that practitioners play an active role in shaping public policy that affects the profession. Review Questions 1. When considering the Emerging Niches Practice Areas and Health People 2020 initiatives, what opportunities for occupational therapy do you note that cannot be realized within current occupational therapy practitioner employment patterns? 2. What effect do occupational therapy practitioners who work in primary care settings have on health promotion and lifestyle modification? 3. How do you expect the health care needs of the Baby Boomers and Millennials to affect occupational therapy services in the future? SUMMARY Health care systems and occupational therapy services have evolved since the inception of the profession, influenced by population needs, scientific discovery, legislative actions, and available reimbursement structures. To ensure a strong role for occupational therapy in the future, these same factors must be considered and available resources used to maximize occupational therapy potential. Hinojosa (2007) suggested in his Eleanor Clarke Slagle Lecture that “[w]e live in a time of hyperchange—rapid, dramatic, complex, and unpredictable change occurring in today’s society, which creates unprecedented challenges” (p. 629). Challenges also present opportunities for extraordinary growth, change, and innovation in occupational therapy practice. Ultimately, it will be the responsibility of each occupational therapy practitioner to take advantage of opportunities through awareness of population health care trends and Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 4. Evolution and Future of Occupational Therapy Service Delivery 45 CASE EXAMPLE 4.1. Exploring Stakeholders and Partnerships for New Programming You have been hired by a facility in a rural area that serves individuals in a 100-mile radius. Recently your community has become concerned with an influx of refugees into the rural area. A long-standing concern with alcohol addiction in your rural state is magnified by an increase in opioid abuse. You have been tasked to expand an already existing occupational therapy department that has historically provided inpatient and outpatient hospital-based services for individuals with physical conditions. Recently your department has established contracts with a local SNF, elementary school, and high school. The facility administrator has encouraged you to be innovative and expand community programming but cautioned you to maintain awareness of cost containment and reimbursement. Review Questions 1. 2. 3. 4. What do you need to know about the populations and culture within the area? What will you consider regarding legislation that influences those populations? What community partnerships might you pursue? How might reimbursement influence program development? emerging occupational therapy service models coupled with support of political action advocacy. Use Case Example 4.1. to explore the variables that practitioners should consider when building new programs. ❖ ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ B.1.2. Sociocultural, Socioeconomic, Diversity Factors, and Lifestyle Choices ■ B.1.3. Social Determinants of Health ■ B.3.1. OT History, Philosophical Base, Theory, and Sociopolitical Climate ■ B.4.19. Consultative Process ■ B.4.20. Care Coordination, Case Management, and Tran■ ■ ■ ■ ■ sition Services B.4.27. Community and Primary Care Programs B.4.29. Reimbursement Systems and Documentation B.5.1. Factors, Policy Issues, and Social Systems B.5.2. Advocacy B.5.4. Systems and Structures That Create Legislation. REFERENCES AARP. (2015). How an OT or CAPS can make a home a good fit. Retrieved from https://www.aarp.org/livable–communities/info -2014/using-an-OT-or-CAPS.html Abou-Saleh, M. T., & Christodoulou, G. N. (2016). Mental health of refugees: Global perspectives [Guest Editorial]. BJPysch International, 13(4), 79–81. https://doi.org/10.1192/S2056474000001379 Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi .org/10.5014/ajot.2018.72S217 American Occupational Therapy Association. (n.d.). Events from 1980–1989. Retrieved from http://www.otcentennial.org/events /1980 American Occupational Therapy Association. (2007). AOTA’s Centennial Vision and executive summary. American Journal of Occupational Therapy, 61, 613–614. https://doi.org/10.5014 /ajot.61.3.267 American Occupational Therapy Association. (2013). Telehealth. American Journal of Occupational Therapy, 67(Suppl. 6), S69–S90. https://doi.org/10.5014/ajot.2013.67S69 American Occupational Therapy Association. (2014a). Guidelines for supervision, roles, and responsibilities during the delivery of occupational therapy services. American Journal of Occupational Therapy, 68(Suppl. 3), S16–S22. https://doi.org/10.5014 /ajot.2014.686S03 American Occupational Therapy Association. (2014b). Occupational therapy framework: Domain and process (3rd ed.). 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Please report unauthorized use to [email protected] 46 SECTION I. Foundations of Occupational Therapy Leadership and Management Braveman, B., & Metzler, C. A. (2012). Health care reform implementation and occupational therapy [Health Policy Perspectives]. American Journal of Occupational Therapy, 66(1), 11–14. https://doi.org/10.5014/ajot.2012.661001 Brown, R. L., Richman, J. A., & Rospenda, K. M. (2017). Economic stressors and psychological distress: Exploring age cohort variation in the wake of the Great Recession. Stress and Health, 33, 267–277. https://doi.org/10.1002/smi.2705 Buchmueller, T. C., Levinson, Z. M., Levy, H. G., & Wolfe, B. L. (2016). Effect of the Affordable Care Act on racial and ethnic disparities in health insurance coverage. American Journal of Public Health, 106, 1416–1421. https://doi.org/10.2105/AJPH.2016.303155 Cason, J., & Jacobs, K. (2014, August 11). Snapshots of current telehealth applications in occupational therapy. OT Practice, 19, 7–12. https://www.cchpca.org/sites/default/files/2018-10/CCHP _50_State_Report_Fall_2018.pdf Center for Connected Health Policy, the National Telehealth Policy Resource Center. (2018). State telehealth laws and regulations— A comprehensive scan of the 50 states and District of Columbia. Retrieved from http://www.cchpca.org/sites/default/files/resources /Telehealth%20Laws%20and%20Policies%20Report%20FINAL %20Fall%202017%20PASSWORD.pdf Centers for Medicare and Medicaid Services. (n.d.-a). CHIPRA. Retrieved from https://www.medicaid.gov/chip/chipra/index.html Centers for Medicare and Medicaid Services. (n.d.-b). Health care coverage options for military veterans. Retrieved from https:// www.healthcare.gov/veterans/ Centers for Medicare and Medicaid Services. (n.d.-c.). Health insurance plan and network types: HMOs, PPOs, and more. Retrieved from https://www.healthcare.gov/choose-a-plan/plan-types/ Centers for Medicare and Medicaid Services. (n.d.-d). 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Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 4. Evolution and Future of Occupational Therapy Service Delivery Jackson, L. L. (2007). Legislative context of occupational therapy practice in schools and early childhood settings. In L. L. Jackson (Ed.), Occupational therapy services for children and youth under IDEA (3rd ed., pp. 1–22). Bethesda, MD: AOTA Press. Jacobs, K. (2011). Evolution of occupational therapy delivery systems. In K. Jacobs & G. L. McCormack (Eds.), The occupational therapy manager (5th ed., pp. 37–59). Bethesda, MD: AOTA Press. Johnson, J. (2013). Certified occupational therapy assistants—­ Opportunities and challenges. New York: Routledge, Taylor & Francis Group. Kaiser Family Foundation. (2018, January 24). Summary of the 2018 CHIP funding extension. Retrieved from https://www.kff .org/medicaid/fact-sheet/summary-of-the-2018-chip-funding -extension/ Kashiwa, A., Sweetman, M. M., & Helgeson, L. (2017). Centennial Topics—Occupational therapy and veteran suicide: A call to action. American Journal of Occupational Therapy, 71, 7105100010. https://doi.org/10.5014/ajot.2017.023358 Leland, N. E., Elliott, S. J., O’Malley, L., & Murphy, S. L. (2012). Occupational therapy in fall prevention: Current evidence and future directions. American Journal of Occupational Therapy, 66, 149–160. https://doi.org/10.5014/ajot.2012.002733 Mackenzie, L., Clemson, L., & Roberts, C. (2013). Occupational therapists partnering with general practitioners to prevent falls: Seizing opportunities in primary health care. Australian Occupational Therapy Journal, 60, 66–70. https://doi.org/10.1111/1440 -1630.12030 MCOL. (n.d.). National managed care penetration. Retrieved from http://www.mcol.com/managed_care_penetration Medicare and Medicaid Amendments, Pub. 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Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids National Oceanic and Atmospheric Administration, National Centers for Environmental Information. (2018). U.S. billion-dollar weather and climate disasters. Retrieved from https://www.ncdc .noaa.gov/billions/ Olmstead v. L.C., 527 U.S. 581 (1999). Omnibus Reconciliation Act of 1980, Pub. L. 96–499, 94 Stat. 2599, 2682. Omnibus Reconciliation Act of 1981, Pub. L. 97–35, 95 Stat. 357–933. Parsons, H. (2018). Therapy cap to be reinstated in 2018: Congress fails to take action. Retrieved from https://www.aota.org/Advocacy -Policy/Congressional-Affairs/Legislative-Issues-Update/2017 /Therapy-Cap-Reinstated-in-2018-Congress-Fails-to-Act.aspx 47 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §3502, 124 Stat. 1999, 124 (2010). Retrieved from https://www .congress.gov/111/plaws/publ148/PLAW-111publ148.pdf Polivka, B. J., & Chaudry, R. V. (2018). A scoping review of environmental health nursing research. Public Health Nursing, 35(1), 10–17. https://doi.org/10.1111/phn.12373 Posmontier, B., & Breiter, D. (2012). Managing generalized anxiety disorder in primary care. Journal for Nurse Practitioners, 8, 268–274. https://doi.org/10.1016/j.nurpra.2011.09.018 Quiroga, V. A. (1995). Occupational therapy: The first thirty years 1900–1930. Rockville, MD: American Occupational Therapy Association. Roosevelt, F. D. (1944, January 11). State of the Union message to Congress. Retrieved from http://www.fdrlibrary.marist.edu /archives/address_text.html Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, M. (2016, January 1). Increases in drug and opioid overdose deaths—United States, 2000–2014. Morbidity and Mortality Weekly Report, 64, 1378–1382. Retrieved from https://www.cdc.gov/mmwr/preview /mmwrhtml/mm6450a3.htm Salama, V. (2017, October 26). Trump’s emergency declaration on opioid crisis will require further funding. Retrieved from https://www.nbcnews.com/storyline/americas-heroin-epidemic /trump-s-emergency-declaration-opioid-crisis-will-require -further-funding-n814416 Schneider, E. C., Sarnak, D. O., Squires, D., Shah, A., & Doty, M. M. (2017, July). Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. healthcare. Retrieved from https://interactives.commonwealthfund.org/2017 /july/mirror-mirror/ Semega, J. L., Fontenot, K. R., & Kollar, M. (2017, September). Income and poverty in the United States: 2016 (Current Population Reports, pp. 60–269). Washington, DC: U.S. Government Printing Office, Economics and Statistics Administration. Retrieved from https:// www.census.gov/content/dam/Census/library/publications /2017/demo/P60-259.pdf Social Security Administration. (n.d.). Notes and Brief Reports— Health Maintenance Organization Act of 1973. Retrieved from https://www.ssa.gov/policy/docs/ssb/v37n3/v37n3p35.pdf Social Security Act of 1965, Pub. 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Census Bureau projections show a slower growing, older, more diverse nation a half century from now. Retrieved from https://www.census.gov/newsroom/releases /archives/population/cb12-243.html (release No. CB12-243) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 48 SECTION I. Foundations of Occupational Therapy Leadership and Management U.S. Census Bureau. (2015a). Millennials outnumber baby boomers and are far more diverse (Release No. CB15-113). Retrieved from https://www.census.gov/newsroom/press-releases/2015/cb15 -113.html U.S. Census Bureau. (2015b). New Census Bureau report analyzes U. S. population projections (Release No. CB15-TPS.16). Retrieved from https://www.census.gov/newsroom/press-releases/2015/cb15 -tps16.html U.S. Census Bureau. (2017). The nation’s older population is still growing, Census Bureau reports (Release No. CB 17–100). Retrieved from https://www.census.gov/newsroom/press-releases /2017/cb17-100.html U.S. Census Bureau. (2018a). Poverty. Retrieved from https://www .census.gov/topics/income-poverty/poverty.html U.S. Census Bureau. (2018b). U.S. and world population clock. Retrieved from https://www.census.gov/popclock U.S. Department of Defense. (2015). 2015 Demographics—­Profile of the military community. Retrieved from http://download.militaryone source.mil/12038/MOS/Reports/2015-Demographics-Report.pdf U.S. Department of Health and Human Services. (n.d.). State children’s health insurance program—Program description. Retrieved from https://www.benefits.gov/benefits/benefit-details/607 U.S. Department of Health and Human Services. (2017). 2020 LHI topics. Retrieved from https://www.healthypeople.gov/2020 /leading-health-indicators/2020-LHI-Topics U.S. Department of Veterans Affairs. (2016, July 7). VA conducts nation’s largest analysis of veteran suicide. Retrieved from https:// www.va.gov/opa/pressrel/pressrelease.cfm?id=2801 U.S. National Library of Medicine. (n.d.). Managed care—Summary. Retrieved from https://medlineplus.gov/managedcare.html Vennes, D. (Ed.). (2009). Taber’s cyclopedic medical dictionary (21st ed.). Philadelphia: F. A. Davis. Vincent, G. K., & Velkoff, V. A. (2010). The next four decades— The older population in the United States: 2010–2050 (Release No. P25-1138). Washington, DC: U.S. Census Bureau. Retrieved from https://www.census.gov/prod/2010pubs/p25-1138.pdf Wall, M. B. (2015). History of hospitals. Retrieved from https://www .nursing.upenn.edu/nhhc/nurses-institutions-caring/history -of-hospitals/index.php Wells, S. A., Black, R. M., & Gupta, J. (Eds.). (2016). Culture and occupation: Effectiveness for occupational therapy practice, education, and research (3rd ed.). Bethesda, MD: AOTA Press. White House, Office of the Press Secretary. (2017, October 12). Presidential executive order promoting healthcare choice and competition across the United States. Retrieved from https://www .whitehouse.gov/the-press-office/2017/10/12/presidential -executive-order-promoting-healthcare-choice-and-competition World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice. Retrieved from http://apps.who.int/iris/bitstream/10665/70185/1/WHO_HRH _HPN_10.3_eng.pdf?ua=1 World Health Organization. (2012). Understanding and addressing violence against women: Human trafficking. Retrieved from http://apps.who.int/iris/bitstream/10665/77394/1/WHO_RHR _12.42_eng.pdf World Health Organization, Regional Office for Europe. (2014, October 12). A public health approach to human trafficking. Retrieved from http://www.euro.who.int/en/health-topics/health -determinants/migration-and-health/news/news/2014/12/a-public -health-approach-to-human-trafficking Yamkovenko, S. (n.d.). The emerging niche: What’s next in your practice? Retrieved from https://www.aota.org/Practice/Manage /Niche.aspx Yuen, J. K., Sincher, H. S., Semon, M. R., Winwood, L. M., & Dudgeon, B. J. (2017). Perceptions of occupational therapists on the Patient Protection and Affordable Care Act: Five years after its enactment. Occupational Therapy in Health Care, 31(1), 84–97. https://doi.org/10.1080/07380577.2016.1270480 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Global Perspectives on Occupational Therapy Practice CHAPTER 5 Elizabeth W. Stevens-Nafai, MSOT, CLT, and Said Nafai, OTD, OTR, CLT LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Self-reflect on cultural humility skills; ■ Describe the history of global occupational therapy organizations, such as the World Federation of Occupational ■ ■ ■ ■ Therapists (WFOT), and global activities such as the Occupational Therapy Global Day of Service; Discuss domestic global perspectives for managers; List 3 current global opportunities for occupational therapy practitioners, managers, and students; Understand an international opportunity in Morocco; and List global resources for domestic and international interests. KEY TERMS AND CONCEPTS • • • • • • • Critical reflection Cultural effectiveness model Cultural humility Cultural relevance Cultural safety Cultural sensitivity Global initiatives • Human rights • Occupational justice • Occupational Therapy Global Day of Service • Occupational Therapy International Online Network OVERVIEW G lobal initiatives identify a topic or area of need and create outreach and collaboration to support this topic or need across national boundaries. How are U.S. occupational therapy practitioners involved in global initiatives? Many opportunities are available to become involved with occupational therapy in a global way, even in daily practice without physically leaving one’s geographical location. The Accreditation Council for Occupational Therapy Education (ACOTE®; 2018) Standards charge occupational therapy practitioners to provide “culturally relevant” (p. 43) screening, evaluation, referrals, and intervention planning and service delivery. Occupational therapy practitioners are expected to acquire skills to provide culturally relevant services in their training, but what happens when an occupational therapy • • • • Professional power Refugees United Nations World Federation of Occupational Therapists manager has a staff needing support in this area? Where do global initiatives fit in with this standard from ACOTE and with daily practice for managers and their staff? This chapter draws on current evidence-based practices using the cultural effectiveness model to educate occupational therapy managers on how to support their staff, as well as a list of 6 marginalized groups who commonly make up the caseloads for the typical occupational therapy practitioner. The chapter then outlines U.S. and international occupational therapy community structures and how occupational therapy practitioners can access these communities to support their daily practice and find relevant global initiatives in which to participate. Current global trends, such as refugee migrations and natural disasters, and an example of an international occupational therapy experience in Morocco, illustrate ways in which an occupational therapy manager can use the skills discussed in this chapter. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.005 49 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Global Perspectives on Occupational Therapy Practice CHAPTER 5 Elizabeth W. Stevens-Nafai, MSOT, CLT, and Said Nafai, OTD, OTR, CLT LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Self-reflect on cultural humility skills; ■ Describe the history of global occupational therapy organizations, such as the World Federation of Occupational ■ ■ ■ ■ Therapists (WFOT), and global activities such as the Occupational Therapy Global Day of Service; Discuss domestic global perspectives for managers; List 3 current global opportunities for occupational therapy practitioners, managers, and students; Understand an international opportunity in Morocco; and List global resources for domestic and international interests. KEY TERMS AND CONCEPTS • • • • • • • Critical reflection Cultural effectiveness model Cultural humility Cultural relevance Cultural safety Cultural sensitivity Global initiatives • Human rights • Occupational justice • Occupational Therapy Global Day of Service • Occupational Therapy International Online Network OVERVIEW G lobal initiatives identify a topic or area of need and create outreach and collaboration to support this topic or need across national boundaries. How are U.S. occupational therapy practitioners involved in global initiatives? Many opportunities are available to become involved with occupational therapy in a global way, even in daily practice without physically leaving one’s geographical location. The Accreditation Council for Occupational Therapy Education (ACOTE®; 2018) Standards charge occupational therapy practitioners to provide “culturally relevant” (p. 43) screening, evaluation, referrals, and intervention planning and service delivery. Occupational therapy practitioners are expected to acquire skills to provide culturally relevant services in their training, but what happens when an occupational therapy • • • • Professional power Refugees United Nations World Federation of Occupational Therapists manager has a staff needing support in this area? Where do global initiatives fit in with this standard from ACOTE and with daily practice for managers and their staff? This chapter draws on current evidence-based practices using the cultural effectiveness model to educate occupational therapy managers on how to support their staff, as well as a list of 6 marginalized groups who commonly make up the caseloads for the typical occupational therapy practitioner. The chapter then outlines U.S. and international occupational therapy community structures and how occupational therapy practitioners can access these communities to support their daily practice and find relevant global initiatives in which to participate. Current global trends, such as refugee migrations and natural disasters, and an example of an international occupational therapy experience in Morocco, illustrate ways in which an occupational therapy manager can use the skills discussed in this chapter. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.005 49 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 50 SECTION I. Foundations of Occupational Therapy Leadership and Management ESSENTIAL CONSIDERATIONS Culturally Effective Management Cultural relevance refers to the teaching of cultural awareness skills in relevant and effective ways and is often associated with the terms cultural humility, cultural sensitivity, cultural safety, human rights, and occupational justice (see Exhibit 5.1; Aronson & Laughter, 2016). These terms are not exclusive to global or international aspects of occupational therapy but are a part of daily practice as well. Hammell (2014) asserted that “Cultures are fluid—not static” and are influenced by factors more diverse than just race and ethnicity, “such as age and generation, gender identity, social position, education, religious affiliation, and exposure to cultural diversity” (p. 42). Crawford et al. (2017) identified 6 groups of clients who often have marginalized human rights and yet comprise the majority of caseloads in the United States for occupational therapy practitioners: Wells et al. (2016) introduced the theory and evidence to support use of the cultural effectiveness model in occupational therapy, through which “culturally effective services are respectful of and responsive to the beliefs and practices and cultural and linguistic needs of diverse populations” (p. 66). On the basis of the cultural effectiveness model, managers with cultural sensitivity skills would have explored their own cultural knowledge and used cultural skills for communication and critical reflection (Wells et al., 2016). Beyond self-­ reflection and self-criticism, 3 additional elements to developing cultural humility are (1) learning from clients, (2) building partnerships, (3) and maintaining lifelong growth in the area of cultural humility (Black, 2016a, p. 55). Understanding the inherent power dynamics in health care, especially the role of the manager regarding professional power with clients who are in a state of disability, is vital. Because “power is an inherent characteristic in this relationship, with the therapist seen as the expert and the client seeking his or her assistance” (Black, 2016b, p. 98), self-awareness is needed to become a culturally humble and sensitive occupational therapy practitioner. 1. 2. 3. 4. 5. 6. People with disabilities, Refugees and asylum seekers, Children, People with mental illness, Indigenous peoples, and Older adults. Crawford et al. argued that “occupational therapists require knowledge and confidence regarding human rights if they are to work effectively with these client groups” (p. 130). It is crucial for occupational therapy practitioners working with these groups of clients to nurture their cultural humility, the ongoing process of building relationships and trust through honest self-reflection of one’s own culture to increase one’s knowledge of other cultures and gain the skills to meet these clients’ needs. Global initiatives can bring cultural differences into sharper contrast, but differences also exist in daily practice as the above list exemplifies. EXHIBIT 5.1. Terms Related to Cultural Relevance ■ Cultural humility: The ongoing process of building relationships ■ ■ ■ ■ and trust through honest self-reflection of one’s own culture to increase one’s knowledge of other cultures. Cultural sensitivity: The ability to recognize but not judge the differences and similarities between people. Cultural safety: A collaborative health care experience for clients in which they feel the health care provider communicates in respectful, inclusive, and empowering ways that recognize that not all people have the same beliefs or act in the same way (Canadian Association of Occupational Therapy, 2011). Human rights: A right that is universally believed to belong to every person, regardless of race, sex, nationality, ethnicity, language, religion, or any other status. Occupational justice: “The right of every individual to be able to meet basic needs and to have equal opportunities and life chances to reach toward her or his potential but specific to the individual’s engagement in diverse and meaningful occupation” (Wilcock & Townsend, 2009, p. 193). Cultural Humility: Self-Reflection All occupational therapy practitioners come with a personal story of who they are and how they got here, just as their clients do. Sometimes their story or background is similar to that of their clients’, but often their backgrounds differ. To fully support clients and colleagues, occupational therapy practitioners must pause and self-reflect on who they are, what biases they may have, or in which areas of cultural humility they have deficits. Deficits or biases often come from lack of knowledge about other cultures. To develop cultural humility skills, occupational therapy practitioners must research and engage the area of deficit to increase their knowledge of their clients and cultural groups with which they have little experience. For example, Level I fieldwork requires students (who, in the United States, are traditionally young adults) to spend time in different settings across the age span, such as visiting assisted living centers to meet older clients, in order to grow cultural sensitivity toward people of other age groups. Cultural effectiveness grows from critical reflection, or the metacognition process of examining knowledge, challenging beliefs, and exploring alternatives. Three stages of the critical reflective process are 1. Awareness, 2. Critical analysis, and 3. New perspectives (Atkins & Murphy, 1993). Raising awareness in the critical reflection process can occur through formal and informal discussions in the classroom and workplace, independent journaling, social media, and local volunteering experiences. Critical analysis is the process of turning inward and truly examining beliefs, behaviors, and unconscious or conscious bias toward the Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 5. Global Perspectives on Occupational Therapy Practice cultural groups being explored. Critical analysis can start with provocative journal or discussion prompts such as, “I think all older people are ” or “People on disability benefits are .” Examining sweeping generalizations can be a jumping-off point to push forward bias and examine deeper beliefs. New perspectives grow from examining this awareness and critical analysis, giving voice to the analysis, expressing these new perspectives, and personal journaling. Participating in a facilitated work or school group is a way to incorporate the new perspectives into personal beliefs. Global Organizations WFOT Globally, the World Federation of Occupational Therapists (WFOT) is the official representative of the occupational therapy profession. WFOT was established in 1952 with 7 countries; now 101 countries are member organizations. WFOT officially began collaborating with the World Health Organization (WHO) in 1959. In 1963, the United Nations (UN) recognized WFOT as a non-governmental organization (NGO; WFOT, 2012). WFOT currently represents 550,000 occupational therapists worldwide (WFOT, 2018). Registered occupational therapy practitioners and student members participate through trainings, certifications, online tools, and attendance at WFOT congresses, which occur every 4 years. Occupational therapy practitioners and students have many structured and unstructured opportunities in which to incorporate global perspectives of occupational therapy practice. Occupational therapy managers can support global activities, on a local level at the facility they manage, in several ways. For example, Occupational Therapy Global Day of Service is a yearly event to celebrate World Occupational Therapy Day. Occupational therapy practitioners and students are able to participate globally in local events with activities such as blood drives and playground repairs (Jacobs, 2017). OTVx Another global event is the Occupational Therapy Virtual Exchange (OTVx). Since 2010, occupational therapy practitioners and students from around the world participate in a free online conference, typically for 24 hours. The OTVx was started as a collaboration among 6 occupational therapy practitioners from Australia, Canada, New Zealand, the United Kingdom, and the United States. Speakers from around the world give presentations on topics such as “Conflict and Emergencies” by Handicap International or “Global Cooperation for Assistive Technology” by WHO (Hook, 2017). WHO The WFOT executive management team attends several WHO meetings each year to nurture this collaboration and advance the occupational therapy profession. For example, occupational therapy practitioners were among attendees at 51 the 2017 WHO Global Research, Innovation, and Education in Assistive Technology summit held at WHO headquarters in Geneva, Switzerland. At least 10 occupational therapy practitioners were invited by WHO among the 150 top researchers, innovators, and educators in the field of assistive technology (WHO, 2017). Domestic Global Perspectives The American Occupational Therapy Association (AOTA) recently published Vision 2025 as its vision statement. Vision 2025 grew out of stakeholder research and built upon the previous Centennial Vision (AOTA, 2007), which used specific language of a “globally connected and diverse workforce” (p. 1). Vision 2025 omits this direct phrase and uses broader language with additional “pillars” to elaborate on the intended audience, specifically the pillar stating that occupational therapy will be “Accessible: Occupational therapy provides culturally responsive and customized services” (AOTA, 2007, 2017c, p. 71). The Vision 2025 sentiment is intentionally inclusive and implies that occupational therapy providers need to develop their cultural humility skills to provide such customized services. AOTA has multiple resources, both in print and digitally, about developing a global perspective for occupational therapy managers, practitioners, and students. For example, OT Practice is a monthly magazine with a section that addresses areas of global interest. In addition, the AOTA Press has published Culture and Occupation: Effectiveness for Occupational Therapy, Practice, Education, and Research, 3rd Edition (Wells et al., 2016), to foster culturally effective, globally minded practice. To support diversity, AOTA has translated important documents and videos into Spanish and Chinese with the help of its members and other national occupational therapy associations. For example, a popular video, “The Distinct Value of OT,” translated into Chinese and Spanish, connects occupational therapy practitioners and students globally to the value of the occupational therapy profession (AOTA, 2014). CommunOT (https://communot.aota.org) is AOTA’s webbased clearinghouse of information available to its members, through which a member can subscribe to groups and receive email updates. Topics such as “international,” “disaster relief,” “multicultural/diversity,” and “international fieldwork opportunities” can be found there. Group members can pose questions in this digital community. CommunOT addresses such topics as how students can participate in international fieldwork on the members’ portion of the website. Review Questions 1. Are you a member of a unique community, perhaps an ethnic, racial, or linguistic group that can serve as a guide for others? If so, how might you go about offering insight into your community? If not, where might you find resources or people to provide information on this group? 2. You are the occupational therapy clinical fieldwork supervisor for a small outpatient hand clinic. A local occupational therapy graduate program placed a Level II Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 52 SECTION I. Foundations of Occupational Therapy Leadership and Management fieldwork student who has not shown up to scheduled Saturday hours. After discussion with the student, he revealed that his Jewish faith prohibits work on Saturdays, but he was unsure about telling you ahead of time. What is the next step you should take? a. Tell him that the clinic is open 6 days a week, and he must follow your caseload schedule closely to complete his fieldwork successfully. b. Tell the school not to send you any more students who cannot follow your schedule, and interview students before placement in the future to be sure they can meet your needs. c. Get in touch with a local synagogue and ask about typical work schedules of congregation members. d. Make a plan with the student that fits his religious needs, and attend a poster presentation at the next AOTA Annual Conference & Expo on how to support fieldwork students with diverse cultural needs. 3. As the occupational therapy manager at a Florida inpatient mental health facility, you notice a recent increase in patients who speak Spanish and are of Puerto Rican descent or nationality, many of whom present with diagnoses related to posttraumatic stress disorder. Considering the recent natural disasters in Puerto Rico and the many residents who have been displaced or who have been without power or resources, you decide that the best professional development to serve this population in the coming months is for you to participate in a. Attending a semester of night classes in Spanish at the local vocational school. b. Interviewing local members of the Puerto Rican community on the status of the island after the disaster. c. Monitoring the National Oceanic and Atmospheric Administration’s website for hurricane watches and warnings to reassure patients more hurricanes are not happening soon. d. Enrolling in a 5- to 10-week certification course in disaster management from WFOT. PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Globalization and access to the Internet and social media make it possible to learn about, connect to, and even join people from other countries in events related to occupational therapy. Humanitarian Crises The UN (2017), which is charged with protecting human rights globally, reached out to all its member countries, NGOs, and other stakeholders to collaborate and strengthen the response to humanitarian crises. During the past 2 decades, the world has seen many humanitarian crises as a result of wars, conflicts, and natural disasters, that led to the displacement of millions of people from their homes, according to United Nations High Commissioner for Refugees (UNHCR; 2016). Refugees are people who have had to leave their nation of birth to seek safety from violence, war, or persecution. By 2016, as a result of worldwide humanitarian crises, there are more than 17 million refugees, about 3 million asylum seekers, more than 36 million internally displaced people, 7 million returned refugees, and more than 3 million stateless persons (UNHCR, 2016). These disasters result in the disruption of daily occupations. AOTA’s official document on disaster response and risk reduction outlines the distinct value and ethical considerations for intervening in disasters: “Occupational therapy is an evidence-based profession that can be an integral component of comprehensive and sustainable disaster response and risk-reduction efforts at the local, state, national, and international levels” (AOTA, 2017a, p. 2). WFOT’s (2014) position statement on disaster preparedness and response (see Appendix 5.A) includes the organization’s statement on how to prepare for and respond to disasters. In it, WFOT also argues why disaster response is important for society and occupational therapy, and brings awareness to the challenges and strategies necessary to provide an effective response to disasters. WFOT (2014) resources include position statements about diversity and culture, human displacement, and occupational therapy in disaster preparedness and response. Occupational therapy practitioners and students need to be aware of resources for helping people who experience disruption in their daily occupations. WFOT (2016b) has compiled a guide, endorsed by 5 global associations with experience in international emergencies, on the do’s and don’ts for rehabilitation professionals responding internationally to disasters. The 23-item list gives examples of everything from equipment donations to documentation to self-care upon return home (WFOT, 2016b). Occupational therapy managers can encourage these do’s and don’ts for practitioner self-care and reflection for their staff, whether responding to a disaster abroad or at home. Natural Disasters On January 12, 2010, Haiti experienced a massive earthquake that killed more than 200,000 Haitians (WHO, 2011a). The earthquake also destroyed the fragile health care system in Haiti. The earthquake injured 300,000 Haitians and initially displaced 1.5 million people; 37,867 people remain displaced as of September 2017 (CNN, 2017). This disaster ultimately brought an aid response from the global community spearheaded by the WHO, United Nations, Red Cross, and other NGOs. The volunteer therapists of Healing Hands for Haiti (HHH) were among the first to reach Haiti, bringing needed rehabilitation equipment and providing free occupational therapy services to Haitians affected by the earthquake. This was detailed in the interview-based qualitative research case study by Riggers (2011) that comprised a series of interviews with Hope (name changed for privacy), an occupational therapy volunteer who arrived in Port-au-Prince on February 15, 2010, a month after the earthquake. Clients and stakeholders welcomed an occupational therapy education program in Haiti. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 5. Global Perspectives on Occupational Therapy Practice Among the occupational therapy personnel was Janet O’Flynn, an occupational therapy practitioner from the United States. O’Flynn worked tirelessly to create a team of occupational therapy practitioners and faculty to help Haiti’s earthquake victims. Furthermore, O’Flynn attended AOTA’s Annual Conference & Expo to connect with more occupational therapy practitioners to help her create a new occupational therapy education program in 2015 in Leogane. The first occupational therapy cohort will be graduating in 2019 (J. O’Flynn, personal communication, April 30, 2017). Virtual Platforms In 2016, WFOT launched the Occupational Therapy International Online Network (OTION), a virtual platform to give occupational therapy practitioners and students from across the world a place to network, share ideas, and communicate about topics concerning occupational therapy. OTION is a free resource with the following sections: education, practice, research, students, working in another country, studying in another country, and congress (WFOT, 2016a). When occupational therapy students and practitioners prioritize membership in WFOT, they benefit from the opportunity to be connected to more than 101 WFOT member countries and more than 550,000 occupational therapy practitioners around the world (WFOT, 2017). Research In response to the World Report on Disability (WHO, 2011b), WFOT identified international research priorities through a 2017 Delphi study to determine common themes of research to address health care through the lens of occupational therapy (WFOT et al., 2017). The rationales and scopes of 8 research priorities were culled from the responses of occupational therapy practitioners from 46 countries, including the United States, and are applicable to most settings of U.S. occupational therapy practice: 1. 2. 3. 4. 5. 6. Effectiveness of occupational therapy interventions, Evidence-based practice and knowledge translation, Participation in everyday life, Healthy aging, Occupational therapy and chronic conditions, Sustainable community development and population-­based occupational therapy interventions, 7. Technology and occupational therapy, and 8. Occupational therapy professional issues (WFOT et al., 2017). Occupational therapy managers, practitioners, and students can choose to conduct research in these priority areas to further the international research priorities, or they may simply choose to take a few minutes to participate in the next survey or similar study that comes their way via social media, email, or other research stream to support fellow occupational therapy researchers and global initiatives. Case Example 5.1 illustrates finding international opportunities. Gail Whiteford (2011), an occupational therapist, international researcher, and professor, challenges occupational 53 therapy practitioners to look for the marginalized segments of a population, the people who are being occupationally deprived and socially excluded, as a key population with which to intervene. Occupational deprivation is “a state in which people are precluded from opportunities to engage in occupations of meaning due to factors outside their control” (Whiteford, 2000, p. 200). Review Questions 1. Review the WFOT Disaster Preparedness and Response Position Statement (Appendix 5.A). Do you feel you possess the skills to address the 8 bulleted “specific roles post-disaster”? If so, which ones? If not, how can you grow your skills to incorporate these demands? 2. A newly arrived El Salvadoran refugee family visited your clinic to receive skilled occupational therapy services for their son with autism spectrum disorder. With the help of interpretation services, you discovered that the family lacks health literacy and the financial means to purchase the recommended compression garment from which the son would benefit. After obtaining consent from the family, what should you do next? a. Nothing; it is a concern for the social worker. b. Inform the school committee where the child attends that he needs a compression garment. c. Create an online crowd-funding account to fund the garment. d. Refer the family to a local church with support services in the community for children with disabilities. 3. Name a recent (within past 12 months) international disaster. Identify where occupational therapy has been involved in the relief work (or could have been if information is unavailable). Has this disaster influenced occupational therapy practitioners in the United States? If you were an occupational therapy manager, what role might you play in this scenario? SUMMARY Occupational therapy practitioners have many opportunities to affect the global community both domestically and internationally, and good managers address these growth opportunities. Duncan (2016) notes that “occupational therapists as change agents must therefore be informed about and, where possible, actively participate in a wide range of public dialogue spaces” (p. 223); being agents of change for global initiatives starts at home and with self-recognition. The cultural effectiveness model can help grow occupational therapy practitioners’ self-reflection, communication, and efficacy to provide culturally relevant care. Participation in local global initiatives, such as the OT Global Day of Service or the OT Virtual Exchange, can be invigorating and informative to local practices by fostering feelings of global connectedness, engaging in public dialogue, and enriching cultural humility skills. Virtual participation in forums like the OT4OT Facebook group is a highly accessible way for Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 54 SECTION I. Foundations of Occupational Therapy Leadership and Management CASE EXAMPLE 5.1. International Opportunities: Morocco As U.S.-trained occupational therapy practitioners, the authors of this chapter have spent more than 10 years volunteering in Morocco during vacation time, breaks in between jobs, teaching courses, and on grants. One of the chapter authors (Dr. Said Nafai) is a native Moroccan and speaks Arabic fluently. Inspired by a sibling with a foot deformity, he pursued first an associate’s degree and then a master’s in occupational therapy. Using their occupational therapy skills, the Nafais started off with summer family vacations visiting elderly family members, then slowly broadened to local community centers for children with disabilities and various outpatient clinics to consult with staff on tough cases. They quickly felt overwhelmed by the level of need they found in Morocco. Once they realized the extensive demand for occupational therapy in Morocco, Said Nafai pursued a doctorate in occupational therapy with the goal of developing an entry-level occupational therapy education program curriculum for Moroccan students. More than just a handful of informal volunteers, mostly from United States, France, and Spain, are required to meet the needs of the nation. When summer vacations no longer sufficed, the Nafais arranged longer trips between job changes, taught an undergraduate course for a semester at a U.S. institution with a campus in Morocco, and finally participated as part of a vocational training team for a Rotary International grant to teach physical therapists how to think like occupational therapy practitioners. This entailed training the physical therapists to ask questions about what the client wished to be able to do more independently that they could not currently do; to look at the layout of the therapy space, to add functional activities to interventions; and most successfully to add play for children’s interventions, rather than relying on more traditional rote exercises for strengthening movements and range of motion. The Nafais began to document their experiences with a series of presentations about the need for occupational therapy in Morocco at national AOTA conferences and in OT Practice. Additionally, they gathered a circle of non–occupational therapy professionals in Morocco to support their endeavors, to show these doctors, physiatrists, dentists, and neurologists the value and role of occupational therapy. In fact, there is not just a dearth of occupational therapy practitioners but of doctors as well; the physician-to-population ratio in Morocco in 2014 was 0.618 to 1,000 (WHO, 2016). Although both physical and speech therapists are trained and work in Morocco, no domestically trained occupational therapy practitioners existed in the Moroccan health care system or education program until September 2017. At this time, after years of collaboration with national stakeholders and WFOT approval, a public health institute, Instituts Supérieurs des Professions Infirmières et Techniques de Santé in the capital city of Rabat, opened the first occupational therapy education program in the country. The school accepted 20 students in the first cohort. In December 2017, the WFOT recognized Morocco as a full member. Currently, there are opportunities to volunteer throughout Morocco as either a student or a practitioner to supervise occupational therapy students, because there is still a lack of occupational therapy practitioners in Morocco until the first cohort of students graduates from the Rabat occupational therapy education program. The Nafais organize service learning trips for occupational therapy students and practitioners and those of other related health and social science fields who wish to volunteer in Morocco while experiencing a cultural exchange. AOTA’s (2017b) “General Guide for Planning International Fieldwork” can help students confirm that their fieldwork abroad meets ACOTE Standards. Review Questions 1. Go to the www.wfot.org website. On the “Membership” icon, click on “Country and Organisation Profile.” Select a country, check its national occupational therapy association’s website, and answer these questions: ■ When was the association of the selected country founded? ■ Does the definition of occupational therapy differ from that of your own national occupational therapy association? ■ What is the word for occupational therapy in the language of the selected country? Does this word translate directly to mean “occupational therapy,” or does it have a slightly different meaning or context than in the United States (e.g., in Chinese occupational therapy was initially translated as “assignments therapy”). ■ How many occupational therapy practitioners are members of the chosen organization? ■ Does this organization provide any professional development and training to its members? What are the professional development requirements for that country? occupational therapy practitioners around the world to support global initiatives and foster discussions for growth. Using the free and paid membership resources available through AOTA and WFOT can bolster occupational therapy managers in daily practice. For example, AOTA’s tip sheets are available in English and Spanish, and the public and members’ forums in CommunOT on AOTA’s website can help uncover additional resources. The “Cultural Competency Tool Kits” are part of the umbrella of multicultural, diversity, and inclusion networks; 7 networks that provide information on cultural norms for a variety of groups found in the United States (AOTA, 2018). The Delphi research study mentioned earlier in this chapter identified 8 priority areas to support occupational therapy practice at home and abroad (WFOT et al., 2017). Disaster preparedness training through WFOT can help occupational therapy managers prepare for large magnitude emergencies in their areas and to support people in affected areas domestically and abroad. Finding opportunities to affect people’s lives internationally is much easier than before. Opportunities such as international service learning and International Level I and Level II fieldwork will allow one to have a closer look at the host country’s culture, health care system, and education. Even after return from an international experience, one can still connect with staff and clients from the host country via telehealth. Lastly, the unique initiatives from Morocco described in this chapter exemplify the spirit of global perspectives in occupational therapy. Case Examples 5.2 and 5.3 are real Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 5. Global Perspectives on Occupational Therapy Practice 55 CASE EXAMPLE 5.2. Domestic Cultural Experience A school-based occupational therapy practitioner in a large urban school district was assigned initial evaluation of incoming 3- and 5-year-old siblings with suspected disabilities to determine possible eligibility for special education via an individualized education plan. The early intervention background referral information for the children revealed that their native language was Nepali and that the family had relocated from Nepal 4 years earlier. Because she had never worked with a family from Nepal before and did not want to do something that could inadvertently be considered rude or disrespectful, the occupational therapy practitioner performed a brief Google search for “culture and etiquette norms of Nepal.” She learned from multiple sources that certain hand gestures and phrases were considered impolite. Although the information was not from an evidence-based journal review or personal testimony from a member of that cultural group, the occupational therapy practitioner felt more comfortable interviewing the family (via a Nepali interpreter) after her quick research. Upon meeting the family and the 3-year-old boy, she noticed he had pierced ears with large, heavy gold earrings, something she had never seen in a toddler before. After quick internal reflection, she remembered her research revealed that heavy eye makeup on infant girls was part of cultural decoration of young children in some Nepali families; the occupational therapy practitioner extrapolated that pierced ears and ornate jewelry for boys might be a similar type of decoration. Doing a few minutes of background research allowed the occupational therapy practitioner to let go of her own cultural expectations of what little boys “typically look like” and move into the assessment with no judgments about appearances. Review Questions 1. 2. This case example illustrates cultural humility because the occupational therapy practitioner a. Learned about another culture. b. Reflected on her own knowledge base and cultural assumptions. c. Did her job without judgment. d. Made interpretations of Nepalese culture because of her research. The best next step after the family had left the evaluation is to a.Ask the interpreter, a member of the Nepali community, a few questions regarding the cultural norms, including confirmation that the gold earrings held a cultural significance. b. Do an Internet search on the significance of gold earrings on boys from Nepal. c.Let the school administration know that the toddler had on earrings that could be considered a safety risk to himself and peers if they got caught on them. d.Add into her evaluation report that parents should not allow their son to wear large heavy gold earrings to preschool for his personal safety both from injury and fear of gold theft in the urban school district. CASE EXAMPLE 5.3. Supporting Refugees at Home At a local children’s hospital, an occupational therapy practitioner, Sally, was working with a 10-year-old boy, Nabil, who had bilateral transhumeral amputations after a bomb explosion in his Syrian hometown. Nabil had spent time in Jordanian refugee camps with initial medical care. A nonprofit humanitarian aid group obtained a medical visa and sponsorship for Nabil and his father to travel to the United States for medical treatment. Through a lengthy medical process of intervention, Nabil was finally ready to begin using his conventional body-powered hook prosthetics. Nabil made great progress in the clinic, and he was able to manipulate many objects successfully from occupational therapy training with the medical interpreter and Sally’s demonstrations. As Sally began to address more complex ADLs with Nabil, his father asked that the training stop, stating, “I will do it for him.” Sally tried to explain that Nabil’s father would not be with Nabil at school and that eventually Nabil would have to manage toilet hygiene and similar issues independently. Realizing that there was a barrier to progress for Nabil based on much bigger cultural issues, including cultural discomfort expressed by Nabil’s father, Sally was granted a privacy release and was then able to reach out to the sponsoring humanitarian aid organization director to get help. The aid organization director located a male, Arabic-speaking, Muslim occupational therapy practitioner to work with Nabil and his father on toilet training and other personal ADLs with prosthetics. In a few volunteer sessions at the boy’s home, the male occupational therapy practitioner was able to coach Nabil and his father through the toilet hygiene process in a way that respected all concerned. Although this was very atypical to the process for Sally, she used her community resources and put her own ego aside to get Nabil the help he needed in the best manner she could. Review Questions 1. 2. 3. What reasons did Nabil’s father have for stopping ADL training? Do you consider them valid? Did Sally do the right thing by involving people from the community? Explain your answer. Put yourself in Sally’s place and self-reflect on the situation. Name 3 points from Nabil’s case that would have challenged you. What other solutions could you think of to remedy this situation? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 56 SECTION I. Foundations of Occupational Therapy Leadership and Management scenarios that occupational therapy practitioners have experienced. Let the cases serve as models of how occupational therapy practitioners have embraced global initiatives domestically and be a guide for developing new initiatives. ❖ Black, R. M. (2016b). Prejudice, privilege, and power. In S. A. Wells, R. M. Black, & J. Gupta (Eds.), Culture and occupation: Effectiveness for occupational therapy practice, education, and research (3rd ed., pp. 91–102). Bethesda, MD: AOTA Press. Canadian Association of Occupational Therapy. (2011). CAOT position statement: Occupational therapy and aboriginal health. Retrieved from https://www.caot.ca/site/pt/caot_posn_stmt?nav=sidebar ACOTE STANDARDS CNN. (2017). Haiti earthquake fast facts. Retrieved from https:// edition.cnn.com/2013/12/12/world/haiti-earthquake-fast-facts This chapter addresses the following ACOTE Standards: /index.html ■ B.1.2. Sociocultural, Socioeconomic, Diversity Factors, Crawford, E., Aplin, T., & Rodger, S. (2017). Human rights in occuand Lifestyle Choices pational therapy education: A step towards a more occupationally just global society. Australian Occupational Therapy Journal, ■ B.4.0. Referral, Screening, Evaluation, and Intervention 64, 129–136. https://doi.org/10.1111/1440-1630.12321 Plan Duncan, E. M. (2016). Development reasoning in community prac■ B.5.0. Context of Service Delivery, Leadership, and Mantice. In M. B. Cole & J. Creek (Eds.), Global perspectives in profesagement of Occupational Therapy Services sional reasoning (pp. 203–238). Thorofare, NJ: Slack. ■ B.5.1. Factors, Policy Issues, and Social Systems Hammell, K. W. (2014). Belonging, occupation and human well■ B.5.2. Advocacy being: An exploration. 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American Journal Retrieved from http://refugeesmigrants.un.org/global-response of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi United Nations High Commissioner for Refugees. (2016). The world .org/10.5014/ajot.2018.72S217 in numbers. Retrieved from http://popstats.unhcr.org/en/overview American Occupational Therapy Association. (2007). AOTA’s Wells, S. A., Black, R. M., & Gupta, J. (2016). Model for culture efCentennial Vision and executive summary. American Journal fectiveness. In S. A. Wells, R. M. Black, & J. Gupta (Eds.), Culture of Occupational Therapy, 61(6), 613–614. https://doi.org/10.5014 and occupation: Effectiveness for occupational therapy practice, /ajot.61.6.613 education, and research (3rd ed., pp. 65–79). Bethesda, MD: American Occupational Therapy Association. (2014). Spanish and AOTA Press. Chinese translations: Making OT globally connected. Retrieved Whiteford, G. (2000). Occupational deprivation: Global challenge from https://www.aota.org/Publications-News/AOTANews/2014 in the new millennium. British Journal of Occupational Therapy, /Translations.aspx 63, 200–204. https://doi.org/10.1177/030802260006300503 American Occupational Therapy Association. (2017a). AOTA’s sociWhiteford, G. (2011). From occupational deprivation to social incluetal statement on disaster response and risk reduction. American sion: Retrospective insights. British Journal of Occupational TherJournal of Occupational Therapy, 71(Suppl. 2), 7112410060. apy, 74, 545. https://doi.org/10.4276/030802211X13232584581290 https://doi.org/10.5014/ajot.2017.716S11 Wilcock, A. A., & Townsend, E. A. (2009). Occupational justice. In American Occupational Therapy Association. (2017b). InternaE. B. Crepeau, E. S. Cohn, & B. A. Boyt Schell (Eds.), Willard tional fieldwork. Retrieved from https://www.aota.org/Practice and Spackman’s occupational therapy (11th ed., pp. 192–199). /Manage/Intl/InternationalFW.aspx Baltimore: Lippincott Williams & Wilkins. American Occupational Therapy Association. (2017c). Vision 2025. World Federation of Occupational Therapists. (2012). History. American Journal of Occupational Therapy, 71, 7103420010. Retrieved from http://www.wfot.org/AboutUs/History.aspx https://doi.org/10.5014/ajot.2017.713002 World Federation of Occupational Therapists. (2014). Occupational American Occupation Therapy Association. (2018). Cultural comTherapy in Disaster Preparedness and Response (DP&R) CM2014. petency tool kits. Retrieved from https://www.aota.org/Practice Retrieved from http://www.wfot.org/ResourceCentre.aspx /Manage/Multicultural/Cultural-Competency-Tool-Kit.aspx World Federation of Occupational Therapists. (2016a). OT interAronson, B., & Laughter, J. (2016). The theory and practice of culnational online network (OTION). Retrieved from http://www turally relevant education: A synthesis of research across content .wfot.org/Groups/OTInternationalOnlineNetworkOTION.aspx areas. Review of Educational Research, 86, 163–206. https://doi World Federation of Occupational Therapists. (2016b). Responding .org/10.3102/0034654315582066 internationally to disasters: A do’s and don’ts guide for rehabiliAtkins, S., & Murphy, K. (1993). Reflection: A review of the littation professionals. Retrieved from http://www.wfot.org/Portals erature. Journal of Advance Nursing, 18, 118–119. https://doi /0/PDF/2016/Dos%20and%20Donts%20in%20Disasters%20 .org/10.1046/j.1365-2648.1993.18081188.x April%202016.pdf Black, R. M. (2016a). The changing language of cross-cultural pracWorld Federation of Occupational Therapists. (2017). Member tice. In S. A. Wells, R. M. Black, & J. Gupta (Eds.), Culture and organisations of WFOT. Retrieved from http://www.wfot.org occupation: Effectiveness for occupational therapy practice, education, and research (3rd ed., pp. 51–61). Bethesda, MD: AOTA Press. /Membership/MemberOrganisationsofWFOT.aspx Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 5. Global Perspectives on Occupational Therapy Practice World Federation of Occupational Therapists. (2018). Human resources project. Retrieved from http://www.wfot.org World Federation of Occupational Therapists, Mackenzie, L., Coppola, S., Alvarez, L., Cibule, L., Maltsev, S., . . . Ledgerd, R. (2017). International occupational therapy research priorities: A Delphi study. OTJR: Occupation, Participation and Health, 37, 72–81. https://doi.org/10.1177/1539449216687528 World Health Organization. (2011a). Haiti earthquake 2010: One year later. Retrieved from http://www.who.int/hac/crises/hti /earthquake/en/ 57 World Health Organization. (2011b). World report on disability. Retrieved from http://www.who.int/disabilities/world_report /2011/en/ World Health Organization. (2016). Global health observatory data repository. Retrieved from http://apps.who.int/gho/data/node .main.A1444 World Health Organization. (2017). Global research, innovation, and education in assistive technology: GREAT summit 2017 report. Retrieved from http://www.who.int/iris/handle/10665 /259746 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 58 SECTION I. Foundations of Occupational Therapy Leadership and Management APPENDIX 5.A. WFOT DISASTER PREPAREDNESS AND RESPONSE POSITION STATEMENT INTRODUCTION Occupational Therapy is a profession concerned with promoting health and well-being through occupation. The primary goal of occupational therapy is to enable people to participate successfully in activities of everyday life in a range of environments and participate in community. Occupational therapists (OTs) achieve this outcome by enabling people to do things that will enhance their ability to live meaningful lives. Disasters, both natural and man-made, are occurring more regularly world-wide. The World Federation of Occupational Therapists (WFOT) acknowledges that they can cause loss of life, property damage, and economic loss. They can affect a person’s health, well-being and ability to engage in meaningful activities of life. Community resilience and positive well-being are key themes in disaster response and are supported by meaningful occupation. The World Federation of Occupational Therapists position is that: Occupational therapists facilitate the engagement in meaningful routines and occupations which may be disrupted by disaster. Occupational therapists should be involved in all stages of disaster management at both local and national level. This involvement ranges from immediately post disaster to long term rehabilitation and reconstruction. It also includes planning and preparation. The WFOT notes that effective disaster preparedness and response management also requires long term strategies in collaboration with key stakeholders. SIGNIFICANCE TO SOCIETY Through an occupational focus, disaster-affected communities and people are better served in their ongoing efforts to rebuild their lives and livelihoods, contributing to outcomes that can be sustained by local service providers and systems. Improved occupational engagement promotes positive wellbeing and mental health, enabling greater productivity and community resilience. Occupational therapists engaging with disaster and reconstruction policy, planning and coordination mechanisms, contribute pertinent expertise to response efforts while laying the foundation for more cohesive involvement and response efforts in the event of future disasters. Stronger networking and coordination between local health professionals, government services and projects, and national and international NGO programs, potentially provide for a more integrated, holistic and yet rationalised and self-reliant service framework. At a more practical level, benefits include: better quality, ongoing care and support for individuals and their families, particularly those with psycho-social trauma and physical injuries who will benefit from occupational and community based rehabilitation and support programs; stronger referral and follow-up systems between community care, hospital and rehab centre programs; and more disability and age friendly accessibility in private and public buildings/spaces. Significance to Occupational Therapy Specific roles post-disaster may include but are not limited to: ■ ensuring accessible environments post disaster at all ■ ■ ■ ■ ■ ■ ■ stages of recovery (e.g. in displaced persons camps) and reconstruction (in rebuilding homes and community facilities) to better support participation. organization of daily routines in displaced persons camps and surviving communities to include persons with disabilities and existing illnesses, women, elderly and children facilitating access to mainstream health care services liaison with and encouragement of community leaders and others to reorganize community supports and routines use of everyday occupations to facilitate recovery facilitating the reestablishment of livelihoods assessment of mental health status of survivors for anxiety, depression and suicidal tendencies, with subsequent counselling and occupation-based activities training of volunteers to carry out ‘quick mental health assessment’ and counselling, and to facilitate activities and social connectivity, thus providing more immediate services for greater numbers. Challenges Occupational therapists are challenged to raise awareness of the benefits of occupational therapy and occupation-based community involvement to both government and community leaders. Capacity building is necessary to ensure that occupational therapy volunteers are prepared to undertake disaster response. Strategies For individual occupational therapists, key recommendations include involvement with local community disaster preparedness and planning to include vulnerable groups. For national associations: Through national workshops and capacity building, national associations can support occupational therapists to more effectively be involved in disaster response. For occupational therapists affected by disaster and engaged directly in disaster response, national associations can provide support. For WFOT: Provision of timely responses, distribution of support materials and information package, ongoing support and networking. Source. Reprinted from “Position Statement: Occupational Therapy in Disaster Preparedness & Response (DP&R)” by the World Federation of Occupational Therapists, 2014. Copyright © 2014 by The World Federation of Occupational Therapists (WFOT). ALL RIGHTS RESERVED. Reproduced with permission. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Leading and Managing Within Health Care Systems CHAPTER 6 Marla R. Robinson, MSc, OTR/L, BCPR, BT–C, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ Describe the importance of value-based care, Describe 2 initiatives that are used to improve care delivery and reduce the burden of health care costs, Describe 2 metrics used to measure efficiency in health care delivery, and Discuss 2 strategies for occupational therapy’s role in the delivery of care in health care systems. KEY TERMS AND CONCEPTS • • • • • • • Acute care Acute inpatient rehabilitation Benchmarking Bundled Payment for Care Improvement Case management Centers for Medicare and Medicaid Services Day rehabilitation • • • • • • • • External benchmarking Health care system Home health services Hospital Readmissions Reduction Program Internal benchmarking Lean methodologies Length of stay Long-term acute care OVERVIEW A ssuming a leadership role within health care systems is more of a challenge now than it has ever been. How health care is delivered, received, and reimbursed can change on a daily basis. Leaders need to be prepared to be flexible, innovative, and authentic in their approach and delivery in order to guide their teams through these challenges. This chapter provides an overview of the levels of care, care transitions, challenges in reimbursement that affect care delivery, and important considerations when making decisions. ESSENTIAL CONSIDERATIONS A health care system is the organization of resources, institutions, and people that delivers health care services to meet the health needs of populations. Health care systems can vary in • • • • • • • • Outcomes Outpatient rehabilitation Patient/client satisfaction Primary care Productivity Quality Skilled nursing or subacute rehabilitation Throughput size from single entities to a conglomeration of entities with a common purpose and oversight. They can include 1 or more levels of care. Value-Driven Care Health care systems strive to provide care in the most efficient and effective manner; the goal is to achieve the best clinical outcomes for patients while providing the best customer service. Providing quality care delivered in an efficient manner is essential to payers, health care providers, and consumers. Many agencies monitor and guide health care systems in providing quality care in an efficient manner; examples include the Centers for Medicare and Medicaid Services (CMS), National Quality Forum, and The Joint Commission. CMS is a federal agency that provides health care coverage for beneficiaries, works with state governments to administer Medicaid and other health care coverage, and provides standards Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.006 59 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Leading and Managing Within Health Care Systems CHAPTER 6 Marla R. Robinson, MSc, OTR/L, BCPR, BT–C, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ Describe the importance of value-based care, Describe 2 initiatives that are used to improve care delivery and reduce the burden of health care costs, Describe 2 metrics used to measure efficiency in health care delivery, and Discuss 2 strategies for occupational therapy’s role in the delivery of care in health care systems. KEY TERMS AND CONCEPTS • • • • • • • Acute care Acute inpatient rehabilitation Benchmarking Bundled Payment for Care Improvement Case management Centers for Medicare and Medicaid Services Day rehabilitation • • • • • • • • External benchmarking Health care system Home health services Hospital Readmissions Reduction Program Internal benchmarking Lean methodologies Length of stay Long-term acute care OVERVIEW A ssuming a leadership role within health care systems is more of a challenge now than it has ever been. How health care is delivered, received, and reimbursed can change on a daily basis. Leaders need to be prepared to be flexible, innovative, and authentic in their approach and delivery in order to guide their teams through these challenges. This chapter provides an overview of the levels of care, care transitions, challenges in reimbursement that affect care delivery, and important considerations when making decisions. ESSENTIAL CONSIDERATIONS A health care system is the organization of resources, institutions, and people that delivers health care services to meet the health needs of populations. Health care systems can vary in • • • • • • • • Outcomes Outpatient rehabilitation Patient/client satisfaction Primary care Productivity Quality Skilled nursing or subacute rehabilitation Throughput size from single entities to a conglomeration of entities with a common purpose and oversight. They can include 1 or more levels of care. Value-Driven Care Health care systems strive to provide care in the most efficient and effective manner; the goal is to achieve the best clinical outcomes for patients while providing the best customer service. Providing quality care delivered in an efficient manner is essential to payers, health care providers, and consumers. Many agencies monitor and guide health care systems in providing quality care in an efficient manner; examples include the Centers for Medicare and Medicaid Services (CMS), National Quality Forum, and The Joint Commission. CMS is a federal agency that provides health care coverage for beneficiaries, works with state governments to administer Medicaid and other health care coverage, and provides standards Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.006 59 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 60 SECTION I. Foundations of Occupational Therapy Leadership and Management for quality improvement initiatives. Many agencies report on quality and safety data for consumers to use as they make decisions about health care providers. These ratings identify high-performing hospitals, educate consumers on the safety of hospitals, and provide data to support value-based purchasing. Health care costs in the United States are among the highest in the world, accounting for 17.9% of the GDP in 2016 and resulting in $3.3 trillion in spending (CMS, 2016). CMS has led efforts to reduce health care costs through many value-based projects, including bundled payments, readmission penalties, and quality payment programs. Bundled Payment for Care Improvement (BPCI) is a CMS initiative addressing performance and accountability for an episode of care, with the aim to improve coordination of care across providers and care environments. This initiative includes 4 models of care that address performance and financial accountability for an episode of care for Medicare beneficiaries (Press et al., 2016). The BPCI model was developed to promote coordinated care across providers and through the continuum of care. Forty-eight clinical episodes currently are being evaluated through this payment model. Episodes could include an acute care stay, an inpatient hospital stay through postacute care services for 90 days, the postacute care stay, or a single prospective payment for all services provided. Health care institutions receive a fixed amount for reimbursement to provide the necessary care for an individual for the entire episode of care. Many institutions and health care systems have created clinical pathways to streamline care, reducing variation in practice and associated costs and, when needed, creating collaborative agreements with postacute care institutions for continuity of care. These collaborative agreements often include the extension of clinical pathways and cost sharing in the care of the patient/client and reimbursement received. Studies show that this bundled payment initiative has resulted in a decreased length of stay (LOS; a metric used by health care organizations and systems that reflects the duration of an individual’s hospitalization), increased discharge to home, and stable readmission rates (Iorio et al., 2016). All of these factors contribute to cost savings for the organization. This study found that implementation of clinical care pathways, evidence-based protocols, and improved care coordination were instrumental in improving the quality outcomes for cost containment within this CMS initiative (Iorio et al., 2016). Another initiative by CMS addresses the issue of hospital readmissions through the Hospital Readmissions Reduction Program (HRRP). The 30-day all-cause readmission measure is a risk-standardized readmission rate for Medicare beneficiaries who were hospitalized in an acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge. The rationale for the program is that many readmissions are a result of poor coordination of care, including inadequate planning for transitions from the acute care environment and poor quality of care (Gerhardt et al., 2013). Initial programs included financial penalties for the 30-day all-cause readmission measure for patients with initial admitting diagnoses of heart failure, pneumonia, and acute myocardial infarction. In 2015, elective total knee replacements, total hip replacements, and acute exacerbation of chronic obstructive pulmonary disease were added. In 2017, coronary artery bypass grafts were also included in the program. According to Desai et al. (2016), hospitals subject to penalties under the HRRP demonstrated greater reductions in readmission rates when compared with hospitals not in the program. The changes in these rates were more significant for the diagnoses identified in the HRRP. Providing efficient care in all phases of care, from acute to postacute, is an important component for maximizing cost containment. In addition, providing quality care is imperative for promoting clinical outcomes that support healthier populations. This concept of Value = (Quality + Outcomes)/Cost is at the center of CMS initiatives. In this new approach to providing health care, all providers are held accountable for their contributions to providing high-quality, evidence-based, patient-/client-centered care. Levels of Care and Care Transitions At the center of many efforts to improve care delivery is the aim of enhancing care coordination with a focus on communication among providers, patients/clients, and caregivers. This includes enhanced use of electronic medical records and developing agreements between facilities for improved transitions of care from one level of care to another. A coordinated discharge plan includes a focus on patient/client and caregiver education to facilitate carryover of skills and knowledge to the next level of care. All health care providers, including occupational therapy practitioners, have an essential role in promoting patient-/client-centered, coordinated, and evidence-based care in an efficient manner. Several levels of care are available: ■ Acute care is care provided in a hospital setting where ■ ■ ■ ■ ■ ■ ■ the treatment of the medical condition is the focus for intervention. Skilled nursing or subacute rehabilitation involves care provided in a facility supporting ongoing medical recovery where the individual may receive skilled rehabilitation care. Acute inpatient rehabilitation is where clients receive skilled rehabilitation services for 3 hours a day requiring at least 2 therapeutic disciplines (occupational, physical, and speech therapy) in addition to nursing care. Clients may receive additional skilled services such as psychological services and recreation therapy. Long-term acute care provides specialized care (e.g., complex wound care, respiratory care services) to its residents in a hospital setting. Day rehabilitation is designed to provide intensive individualized rehabilitation care in an outpatient facility. Home health services involve nursing care and other therapy provided in the individual’s home environment. Primary care is the setting in which an individual receives basic medical care in an outpatient setting. Outpatient rehabilitation involves therapy services provided in an outpatient setting either as part of a hospital or in a stand-alone facility. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 6. Leading and Managing Within Health Care Systems Some health care systems provide several levels of care, allowing for efficient transitions and communication between each level. When facilities are independent of one another, communication for care transitions can become fractured, leading to inefficiencies and discoordination in care provision. Coordinated communication of discharge plans across the levels of care is imperative to ensure that all needs are addressed and carried over, especially with important routines such as medication management and health prevention or promotion tasks. Care coordination is a key tenet of effectively navigating health care systems. All stakeholders, including clients, caregivers, payers, and clinicians, need to be flexible, collaborative, and receptive to new approaches (Robinson et al., 2016) to facilitate effective management of disease processes and transitions from one level of care to another. Care coordination should be interprofessional and client centered; it should engage caregivers and family members, while advocating for the health care needs of clients. The key interventions that have proven to add value to the effectiveness of care transitions include making appointments for follow-up care, organizing postdischarge services, educating patients about their medications, providing individualized education to the client and caregivers, assessing client understanding of discharge education and instructions, and calling patients after discharge to reinforce the discharge plan (Mitchell et al., 2016). Research has shown that when compared with routine discharge care, an individualized discharge plan can reduce hospital LOS and readmissions (Gonçalves-Bradley et al., 2016). LOS and Productivity To provide efficient care and respond to financially driven programs, many health care systems focus on LOS and provider productivity. Service-driven protocols or clinical pathways are developed to structure the care provided to facilitate discharge in a specified LOS within the hospital. These evidence-based clinical pathways are designed to guide the care for each discipline to ensure a coordinated plan for each day and consistent care delivery. Many health care organizations monitor the LOS on a daily basis and have created communication pathways to facilitate the discharge process such as multidisciplinary rounds and care conferences. Throughput, or moving the client through the episode of care while achieving all of the clinical milestones, is an important metric that has financial implications. The shorter the LOS for the entire episode of care, the greater the efficiency and financial return for the health care system. This is especially true for BPCI, managed care products, and negotiated care contracts with payers. Productivity is a metric used in many health care systems to determine efficiency in the delivery of care against an established standard. Along with finance reports, this measure is used to determine whether revenue projections are being met and where opportunities exist in enhancing efficiencies. Many organizations have established productivity metrics through benchmarking with other health care systems or 61 using historical data. For therapy services, productivity is often measured through both billable time for financial purposes and patient visits as a measure of throughput. While many organizations use productivity as a primary metric for performance, achieving positive clinical outcomes is equally important. This brings us back to the discussion of the concept of Value = (Quality + Outcomes)/Cost. Benchmarking Benchmarking is “a standard by which others may be measured or judged” (Benchmark, 2011) and can be used for comparison. In health care systems, benchmarking is used to support decision making with respect to performance in various measures, including productivity, financial targets, clinical processes, and outcomes as comparisons are made to identified standards. Benchmarking is also used as a tool to engage stakeholders to understand how their performance compares to others and provides opportunities to identify areas for improvement. Aparicio et al. (2014) discuss 2 forms of benchmarking: (1) internal and (2) external. Internal benchmarking compares best practices within an organization as well as evaluating performance of the organization over time. External benchmarking assesses performance in comparison to other organizations whose strategies have proven effectiveness. Quality Initiatives The other important components of value are quality and outcomes. Quality care is provided through the consistent use of evidence-based practice that can be measured. The use of outcome measurements to assess and evaluate change over time from admission to discharge provides data that can demonstrate the impact of the care provided. Patient/client satisfaction is a type of outcome consistently measured by health care systems that measures an individual’s perception and attitudes of the care provided and received. Outcome data can be used to determine gaps in care provision leading to quality improvement initiatives or research opportunities that can inform evidence-based practice. Many organizations have implemented lean methodologies to facilitate process improvement throughout the health care system. Lean methodology is used to improve the quality and safety of care for clients, improve work flows for clinicians and staff, and increase financial performance through eliminating inefficiencies and waste (D’Andreamatteo et al., 2015; DiGioia et al., 2015). The principles used to guide lean implementation are applied to all aspects of care delivery in the health care systems through the creation of standard work, a workflow that is able to be replicated by all through standardization. The use of evidence-based practice guidelines provides clinicians with a standard approach to care, leading to fewer medical errors and more efficient care delivery. As part of these practice guidelines, health care systems are implementing the use of order sets within their electronic medical record systems and standardized approaches to all aspects of care delivery. Consistent use of medical tests, consultation requests with various Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 62 SECTION I. Foundations of Occupational Therapy Leadership and Management clinical disciplines, and timing and dosing of medications and interventions are examples of standardized approaches. This approach also includes implementing systems for supply monitoring and restocking to ensure that care providers have the supplies and tools readily available to provide optimal care. Patient/client satisfaction is a quality metric used by many regulatory bodies and payers to assess the care provided by a health care system. Patient/client satisfaction is a reflection of an individual’s perception and attitudes toward their care (Jenkinson et al., 2002). As consumers have choices in health care plans and providers, patient/client engagement and the voice of the customer are important metrics used by health care systems to gauge opportunities for improvement in care delivery (Custer et al., 2015). Areas of assessment related to patient satisfaction include the cleanliness of the facility, friendliness and responsiveness of the care providers, collaboration and coordination of care, perceived quality of the care provided, pain management, cultural competence, and health literacy. Providing patient-/client-centered care and partnering with patients in decision making are important components of client satisfaction (Al-Abri & Al-Balushi, 2014). Marley et al. (2004) stated that measuring satisfaction should include aspects of process components of “how” the service was provided as well as the interpersonal aspects of the care provided. Regulatory bodies and payers are assessing the care provided according to the clinical outcomes, quality indicators, and patient satisfaction outcomes. These metrics are used to determine readiness for various designations, including specialty certifications through different certifying bodies. PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Review Questions Occupational Therapy Contributions to Value-Driven Care 1. Value-based programs were implemented to a. Improve coordination of care. b. Improve quality of care. c. Reduce health care costs. d. All of the above. 2. Strategies to improve care transitions include all except a. A coordinated individualized discharge plan, including the client and caregivers. b. Follow-up telephone call to reinforce discharge education and respond to concerns. c. Medication reconciliation and education. d. Discharge planning assigned to a single provider. e. Providing clients with follow-up appointments at the time of discharge. 3. Benchmarking in health care systems: a. Benchmarking allows comparison in performance with other similar organizations for improvements in different areas of measurement. b. External benchmarking allows comparisons of best practices within an organization. c. Internal benchmarking assesses performance with other organizations. d. Benchmarking sets up competition between organizations for financial gain. Occupational therapy leaders, managers, practitioners, and students have an important role in identifying the distinct value of occupational therapy to health care systems. As mentioned earlier in this chapter, health care delivery is now value driven. Occupational therapy practitioners and students provide care to clients in all contributing environments of health care systems, from acute care through the continuum to postacute care and primary care settings. In each setting, occupational therapy providers are challenged to provide evidence-based care that contributes to positive clinical outcomes for clients in an efficient and effective manner. This care must be provided in a manner reflecting “the core belief that occupational therapy practice is anchored in the meaningful, necessary and familiar activities of everyday life,” demonstrating the distinct value of occupational therapy (Lamb, 2017, p. 3). In her American Occupational Therapy Association (AOTA) Presidential Address, Ginny Stoffel (2013) stated that “leadership is a process of influence. Organizations are healthier when leaders influence others to take action” (p. 634). Each occupational therapy practitioner has the opportunity to be a leader. Leadership can occur at all levels if goals and objectives are understood. Occupational therapy managers and leaders in health care systems are uniquely positioned to influence the actions of others to improve how health care is delivered. Leaders are also required to connect the purpose of initiatives to the outcomes achieved to engage stakeholders in the process. Occupational therapy practitioners work with client populations identified in the BPCI and HRRP initiatives. Occupational therapy managers and leaders need to be recognized as stakeholders in these initiatives and clearly define the critical role occupational therapy plays to facilitate efficiencies in care and reduce readmission rates. Many health care systems have developed clinical pathways to support efficiencies and create standard approaches to clinical care delivery, identifying the role of each discipline. These pathways are designed to reduce redundancies while promoting positive clinical outcomes, from prehospital admission through postacute care environments. Occupational therapy practitioners should be involved in the development and evaluation of the effectiveness of the clinical pathways to ensure that functional needs are addressed to facilitate optimal engagement and participation of clients as they transition through the various levels of care. Occupational therapy practitioners can assist in identifying barriers for discharge early in the process that contribute to inefficiencies in discharge planning. According to Gerhardt et al. (2013), from 2007–2011 the national 30-day all-cause readmission rate was an average of 19%. During the calendar year 2012, this rate dropped Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 6. Leading and Managing Within Health Care Systems to 18.4% and is presumed to be a result of initiatives implemented to address inefficiencies in care delivery. Gage et al. (2012) reported readmission rates of 17.4% for inpatient rehabilitation, 19.8% for skilled nursing facilities, 21.1% for longterm acute care, and 20.2% for home health agencies. As these statistics underscore, readmissions occur in all levels of care, and opportunities to improve care processes can be found at all levels in a health care system. An individual’s functional level has been shown to affect hospital readmissions. DePalma et al. (2013) found that individuals with unmet ADL needs were more likely to be readmitted to a hospital within a year; they reported that 1 in 4 Medicare beneficiaries were discharged with unmet ADL needs. Naylor et al. (2011) reported that most transitional care focuses on medical management for discharge, with few addressing the functional needs of the individual. Occupational therapy practitioners are trained to address the functional needs of individuals, including ADLs, medication management, and health routines to support the highest level of independence, in all settings. Opportunities to collaborate with other disciplines to reduce the risk of hospital readmissions through proactive interventions such as early mobility programs have demonstrated improvements in cognitive function, with fewer days of delirium and better functional outcomes at hospital discharge (Schweickert et al., 2009; Nydahl et al., 2017). Another example includes the role of occupational therapy practitioners in optimizing medication management and subsequent medical adherence through the unique lens of time management, client participation in healthy habits and routines, and the use of assistive technology (Schwartz & Smith, 2017). Focusing on self-management skills is an important factor in health maintenance. Occupation therapy practitioners are experts in identifying opportunities for improvements in task performance through task analysis and then actively engaging clients and caregivers in developing the skills for self-management (Lamb & Metzler, 2014; Roberts & Robinson, 2014). Occupational therapy managers and leaders are expected to identify and support the role of occupational therapy in assessing functional abilities, providing interventions, and recommendations to facilitate appropriate discharge planning and follow up for individuals as they move from one level of care to another. Managers need to ensure that occupational therapy is an identified stakeholder and key participant for discharge planning and decisions. Occupational Therapy’s Role in Care Transitions Occupational therapy practitioners are undertaking roles in care coordination and primary care environments with skills suited to lead care transitions (Lamb & Metzler, 2014). In these roles, therapists are completing assessments and identifying opportunities for enhanced support and intervention for individuals to integrate daily health habits and routines that improve function and participation in ADLs and IADLs while promoting self-sufficiency and independence. 63 The Commission for Case Manager Certification (2017) defines case management as “a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client’s health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes” (para. 1). Occupational therapy practitioners acquire these skills through their formal education. As stated by Robinson et al. (2016), occupational therapy practitioners have a unique lens to assess the intersection of occupation, occupational performance, and individual factors to support successful care transitions. Facilitating roles for occupational therapy practitioners in case management is an opportunity for occupational therapy leaders to positively affect care transitions in health care systems. Many of the initiatives addressing bundled payments and hospital readmissions focus on the LOS in the hospital. Directly related to this is the ability of occupational therapy personnel to evaluate clients in a timely manner, identify appropriate discharge dispositions to initiate transition to the next level of care, and develop an individualized plan of care. Occupational therapy practitioners then provide interventions that are consistent with the frequency and duration identified in the individualized plan of care. Occupational therapy managers develop procedures for timely completion of these tasks that support clinical pathways and established standards of care. Many health care systems have developed procedures to prioritize client populations and diagnoses to facilitate these processes. One way to identify the ability of the team to meet client care needs within a health care system is through tracking individual and aggregated team productivity to report billable time and client visits. These data points are often used to justify current staffing needs or staffing requirements as volumes change over time. These data may be used for internal and external benchmarking to identify gaps in service delivery and opportunities for enhanced efficiency. Occupational therapy managers and leaders are often required to report these metrics as part of a health care system to inform the organization’s financial performance. These data can be used to support decisions for new program development or the need to streamline current programming. Occupational Therapy’s Role in Quality Initiatives Occupational therapy practitioners are ethically responsible for the value of the service they provide to facilitate optimal clinical outcomes for clients (Leland et al., 2015). This is accomplished through consistent use of evidence-based assessments and interventions. These best practice initiatives can assist in identifying the practice gaps in the profession of occupational therapy to inform research initiatives (Braveman, 2016; Lamb & Metzler, 2014; Leland et al., 2015). Occupational therapy managers and leaders need to champion these efforts and provide opportunities for clinicians to Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 64 SECTION I. Foundations of Occupational Therapy Leadership and Management engage in quality initiatives to improve care delivery. This can occur through performance improvement, implementation of lean methodologies for process improvements, or more formally through the development of research projects. The implementation of occupational therapy practice guidelines to reduce variation in clinical practice and enhance efficiencies in outcomes is an effective way to achieve the above-mentioned goals. These practice guidelines are based on systematic reviews of the literature and provide practitioners with assessments and interventions that demonstrate effective outcomes. AOTA (n.d.) provides practice guidelines for specific topics “to support decision making that promotes a high quality health care system” (para. 1). Components of clinical practice guidelines (see Table 6.1) involve a comprehensive review of the research evidence, proposed evaluation tools, outcome measures, and interventions to implement. These guidelines often provide an algorithm for decision making to assist the clinician in efficiency in care provided. As discussed previously, client satisfaction is an important quality initiative in health care systems. Every health care professional has a role in client satisfaction and can influence client and family perceptions of the care delivered. Occupational therapy managers provide education and training to staff on expectations related to customer service, communication standards, and care delivery models for the health care system. Many organizations require leaders to perform rounds with clients in the hospital or postacute facility to solicit feedback on the quality of the facilities, amenities, and communication with and among care providers as well as on the perceived quality of the care received and to provide the opportunity to respond to concerns in a timely manner. In doing so, the facility is provided with the opportunity to intervene immediately with service recovery if needed or to acknowledge the work of individuals or teams that facilitate positive client experiences. Within health care systems, occupational therapy practitioners can provide leadership on committees addressing hospital readmissions, clinical pathway development, care coordination, quality improvement, client satisfaction, clinical innovation, and client education to address concerns of health literacy. Having a presence and ability to contribute as a stakeholder in these initiatives allows occupational therapy to promote healthy transitions through health care systems in an efficient and effective manner. Review Questions 1. Occupational therapy leaders can facilitate the role of occupational therapy providers in reducing hospital readmissions by a. Assisting in optimizing client participation in medication management. b. Collaborating for the implementation of coordinated mobility and early intervention programs. c. Facilitating self-management in establishing health routines that promote healthy lifestyles. d. Participating in the development and evaluation of clinical pathways. e. All of the above. 2. Opportunities for occupational therapy providers to demonstrate leadership roles in care transitions include all except a. Advocating for client needs when resources may be limited. b. Assessing and evaluating functional abilities and identifying barriers for discharge. c. Completing medication reconciliation to ensure no potential concerns for discharge. d. Communicating recommendations for appropriate level of care with the interprofessional team. TABLE 6.1. Criteria for Trustworthy Clinical Practice Guidelines STANDARD DESCRIPTION 1. Transparency Clear description of the funding sources should be readily available. 2. Management of conflict of interest Conflicts of interest for the individuals and groups involved in developing the guidelines should be disclosed and managed as appropriate. 3. Composition of guideline development group The group should be composed of multidisciplinary members (stakeholders, experts, clinicians). 4. Review of the literature The guideline should be based on systematic reviews of the research evidence and literature. 5. Rating strength of evidence and recommendations Each recommendation should include the potential risks and benefits, a summary and quality of the evidence, underlying rationale, rating of the level of confidence in the evidence and the strength of the recommendation, and differences of opinion regarding recommendations. 6. Presentation of recommendations The guideline should include recommended actions, when they should be performed, and how they could be measured. 7. External review The guidelines should be reviewed by relevant stakeholders. 8. Updating Guidelines should include date of development, date of evidence, and date of proposed review; should be updated when new evidence is available. Source. Adapted from Clinical Practice Guidelines We Can Trust by the Institute of Medicine of the National Academies (2011). Available at https://bit.ly/2HhabhJ. In the public domain. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 6. Leading and Managing Within Health Care Systems 65 CASE EXAMPLE 6.1. Acute Care Readmissions Samantha is an occupational therapy practitioner working in an acute care hospital with patients being treated for congestive heart failure (CHF). She is concerned that she continues to see the same clients being readmitted to the hospital with exacerbation of their symptoms. Samantha is aware that her hospital is working on trying to reduce hospital readmissions as part of cost-saving initiatives. She approaches her manager, Nancy, with her concerns. Nancy asks Samantha how the occupational therapy team might contribute to reducing readmissions for clients with CHF. Samantha identifies several opportunities, such as an occupational therapy assessment for patients upon admission to the hospital to assess their habits and routines, including self-management for daily weights, medications, and activities. In addition, she believes that a cognitive assessment may be helpful for clients who live alone and have comorbidities. Nancy suggests that Samantha complete a review of the literature to support occupational therapy interventions with this population. Once she has completed the evidence review, Samantha is asked to develop a standardized clinical pathway for occupational therapy assessments, outcome measurements, and appropriate interventions, including recommended frequency and duration of these interventions. Nancy has recently asked to be included in the organization’s readmissions committee and plans to share the occupational therapy plan for this population. As the manager, Nancy will also need to develop a plan to evaluate the impact of this new pathway and to determine whether these interventions have affected hospital readmissions. She will also need to work collaboratively with the care coordination team and occupational therapy personnel in the other postacute environments to ensure that clients have the resources at home to sustain the healthy habits and routines such as weight scales and home health support when needed. Review Questions 1. 2. 3. Samantha identifies a concern for a high readmission rate for the clients she sees with CHF. What recommendations does her manager recommend to address this concern? a. Complete a literature review for best practices in occupational therapy in working with clients with CHF. b. Develop standardized clinical best practice guidelines for occupational therapy practitioners in working with clients with CHF. c. Identify appropriate outcome measurements to use with clients with CHF. d. All of the above. The value-driven initiatives used in the case example to work toward a positive impact for the health care system include a. Assessment of patient/client satisfaction. b. Clinical pathway development. c. Provision of daily occupational therapy interventions. d. None of the above. Leadership qualities displayed by Nancy include all except a. Coaching. b. Competition. c. Engagement. d. Influencing. 3. Tools used by occupational therapy managers to measure efficiencies in health care systems include a. LOS. b. Productivity. c. Clinical outcome measurements. d. All of the above. Leadership is a collaborative process in all levels of care in a health care system, and the goal for occupational therapy leaders is to engage and influence their teams to take action to provide care in the most efficient and effective manner. Case Example 6.1 illustrates leadership in the health care system. ❖ SUMMARY This chapter addresses the following ACOTE Standards: This chapter provides an overview of the levels of care, care transitions, challenges in reimbursement that affect care delivery, and important considerations for leaders to consider in making decisions in health care systems. Occupational therapy offers distinct value in promoting efficiencies in care delivery in health care systems to reduce LOS, promote throughput, and optimize functional abilities of individuals. Occupational therapy practitioners have opportunities to serve in leadership roles to promote quality improvements, implement lean methodologies, and engage in process improvement to efficiently deliver care. ■ B.1.2. Sociocultural, Socioecomonic, Diversity Factors, ACOTE STANDARDS and Lifestyle Choices ■ B.1.3. Social Determinants of Health ■ B.1.4. Quantitative Statistics and Qualitative Analysis ■ B.2.1. Scientific Evidence, Theories, Models of Practice, and Frames of Reference ■ B.3.1. OT History, Philosophical Base, Theory, and Sociopolitical Climate ■ B.3.3. Distinct Nature of Occupation ■ B.3.4. Balancing Areas of Occupation, Role in Promotion of Health, and Prevention Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 66 SECTION I. Foundations of Occupational Therapy Leadership and Management ■ B.4.6. Reporting Data ■ B.4.19. Consultative Process ■ B.4.20. Care Coordination, Case Management, and Tran■ ■ ■ ■ ■ ■ sition Services B.4.24. Effective Intraprofessional Collaboration B.4.25. Principles of Interprofessional Team Dynamics B.4.27. Community and Primary Care Programs B.4.29. Reimbursement Systems and Documentation B.5.0. Context of Service Delivery, Leadership, and Management of Occupational Therapy Services. B.7.0. Professional Ethics, Values, and Responsibilities. 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American Journal of Occupational Therapy, 69(Suppl. 1), 691150091. https://doi.org/10.5014/ajot.2015.69S1-PO3048 D’Andreamatteo, A., Ianni, L., Lega, F., & Sargiacomo, M. (2015). Lean in healthcare: A comprehensive review. Health Policy, 119, 1197–1209. https://doi.org/10.1016/j.healthpol.2015.02.002 DePalma, G., Xu, H., Covinsky, K. E., Craig, B. A., Stallard, E., Thomas, J., III, & Sands, L. P. (2013). Hospital readmission among older adults who return home with unmet need for ADL disability. Gerontologist, 53, 454–461. https://doi.org/10.1093/geront/gns103 Desai, N. R., Ross, J. S., Kwon, J. Y., Herrin, J., Dharmarajan, K., Bernheim, S. M., . . . Horwitz, L. I. (2016). Association between hospital penalty status under the hospital readmission reduction program and readmission rates for target and nontarget conditions. JAMA, 316, 2647–2656. https://doi.org/10.1001/jama .2016.18533 DiGioia, A. M., Greenhouse, P. K., Chermak, T., & Hayden, M. A. (2015, December). A case for integrating the patient and family centered care methodology and practice in lean healthcare organizations. Healthcare, 3, 225–230. https://doi.org/10.1016/j .hjdsi.2015.03.001 Gage, B., Ingber, M., Smith, L., Deutsch, A., Kline, T., Dever, J., . . . Garfinkel, D. (2012). Post-acute care payment reform demonstration: Final report. Retrieved from https://www.cms.gov/Research -Statistics-Data-and-Systems/Statistics-Trends-and-Reports /Reports/Research-Reports-Items/PAC _Payment_Reform _Demo_Final.html Gerhardt, G., Yemane, A., Hickman, P., Oelschlaeger, A., Rollins, E., & Brennan, N. (2013). Data shows reduction in Medicare hospital readmission rates during 2012. Medicare and Medicaid Research Review, 3(2), E1–E12. https://doi.org/10.5600/mmrr.003.02.b01 Gonçalves-Bradley, D. C., Lannin, N. A., Clemson, L. M., Cameron, I. D., & Shepperd, S. (2016). Discharge planning from hospital. Cochrane Database System Review, CD000313. https://doi .org/10.1002/14651858.CD000313.pub5 Institute of Medicine of the National Academies. (2011). Clinical practice guidelines we can trust. Retrieved from http://national academies.org/hmd/~/media/Files/Report%20Files/2011 /Clinical-Practice-Guidelines-We-Can-Trust/Clinical%20Practice %20Guidelines%202011%20Insert.pdf Iorio, R., Clair, A. J., Inneh, I. A., Slover, J. D., Bosco, J. A., & Zuckerman, J. D. (2016). Early results of Medicare’s bundled payment initiative for a 90-day total joint arthroplasty episode of care. Journal of Arthroplasty, 31, 343–350. https://doi.org/10.1016/j .arth.2015.09.004 Jenkinson, C., Coulter, A., Bruster, S., Richards, N., & Chandola, T. (2002). Patients’ experience and satisfaction with health care: Results of a questionnaire study of specific aspects of care. Quality Safety Health Care, 11, 335–339. https://doi.org/10.1136 /qhc.11.4.335 Lamb, A. J. (2017). Unlocking the potential of everyday opportunities. American Journal of Occupational Therapy, 71, 7106140010. https://doi.org/10.5014/ajot.2017.716001 Lamb, A. J., & Metzler, C. A. (2014). Defining the value of occupational therapy: A health policy lens on research and practice [Health Policy Perspectives]. American Journal of Occupational Therapy, 68, 9–14. https://doi.org/10.5014/ajot.2014.681001 Leland, N. E., Crum, K., Phipps, S., Roberts, P., & Gage, B. (2015). Advancing the value and quality of occupational therapy in health service delivery [Health Policy Perspectives]. American Journal of Occupational Therapy, 69, 6901090010. https://doi .org/10.5014/ajot.2015.691001 Marley, K. A., Collier, D. A., & Meyer Goldstein, S. (2004). The role of clinical and process quality in achieving patient satisfaction in hospitals. Decision Sciences, 35, 349–369. https://doi.org/10.1111 /j.0011-7315.2004.02570.x Mitchell, S. E., Martin, J., Holmes, S., van Deusen Lukas, C., Cancino, R., Paasche-Orlow, M., . . . Jack, B. (2016). How hospitals reengineer their discharge processes to reduce readmissions. Journal for Healthcare Quality, 38(2), 116–126. https://doi .org/10.1097/JHQ.0000000000000005 Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The care span: The importance of transitional care in achieving health reform. Health Affairs, 30, 746–754. https://doi.org/10.1377/hlthaff.2011.0041 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 6. Leading and Managing Within Health Care Systems Nydahl, P., Sricharoenchai, T., Chandra, S., Kundt, F. S., Huang, M., Fischill, M., & Needham, D. M. (2017). Safety of patient mobilization and rehabilitation in the intensive care unit. Systematic review with meta-analysis. Annals of the American Thoracic Society, 14(5), 766–777. https://doi.org/10.1513 /AnnalsATS.201611-843SR Press, M. J., Rajkumar, R., & Conway, P. H. (2016). Medicare’s new bundled payments: Design, strategy, and evolution. JAMA, 315, 131–132. https://doi.org/10.1001/jama.2015.18161 Roberts, P. S., & Robinson, M. R. (2014). Occupational therapy’s role in preventing acute readmissions [Health Policy Perspectives]. American Journal of Occupational Therapy, 68, 254–259. https:// doi.org/10.5014/ajot.2014.683001 Robinson, M., Fisher, T. F., & Broussard, K. (2016). Role of occupational therapy in case management and care coordination for 67 clients with complex conditions [Health Policy Perspectives]. American Journal of Occupational Therapy, 70, 7002090010. https://doi.org/10.5014/ajot.2016.702001 Schwartz, J. K., & Smith, R. O. (2017). Integration of medication management into occupational therapy practice. American Journal of Occupational Therapy, 71, 7104360010. https://doi.org /10.5014/ajot.2017.015032 Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., . . . Kress, J. P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomized controlled trial. Lancet, 373, 1874–1882. https://doi.org/10.1016/S0140-6736(09)60658-9 Stoffel, V. C. (2013). From heartfelt leadership to compassionate care [Presidential Address]. American Journal of Occupational Therapy, 67, 633–640. https://doi.org/10.5014/ajot.2013.676001 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Creating a Business in an Emerging Practice Area CHAPTER Ingrid M. Kanics, OTR/L, FAOTA 7 LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ Define emerging practice area in the field of occupational therapy, Describe current emerging practice areas in occupational therapy, Describe the process of creating an emerging practice business, Identify mentors for an emerging practice, and Create a plan to sustain an emerging practice. KEY TERMS AND CONCEPTS • • • • • Business goals Business model canvas Business plan Emerging areas of practice Evidence review • • • • OVERVIEW T • • • • Formal evaluation Informal evaluation Lean startup plan Mentors hroughout its history, the occupational therapy profession has always responded to the emerging needs of society. From treating the vast number of returning servicemen of World War I to supporting the growing number of children in neonatal intensive care units today, occupational therapy practitioners have been there to address these ever- changing needs. Occupational therapy practitioners have the opportunity to work with people where they live, from their houses to museums, airplanes, and community centers, and are continually adapting their practice areas to meet the continuously growing needs of society. Emerging areas of practice, sometimes referred to as nontraditional practice areas, are areas in which the occupational therapy role has not been established (Overton et al., 2009). In 2011, as part of the American Occupational Therapy Association’s (AOTA) Centennial Vision process, emerging practice areas in occupational therapy were identified (see Exhibit 7.1). Many areas of opportunity are available to occupational therapy practitioners to practice with various populations. Needs assessment Potential partner SMART method Traditional business plan Some examples of societal trends that are creating new areas for occupational therapy practice include the following: ■ The worldwide population of individuals ages 60 years or ■ ■ ■ ■ older currently is 901 million, with the number projected to reach nearly 2.1 billion by 2050 (Barratt, 2017). More than 50% of youth with autism who had left high school in the past 2 years had no participation in employment or education (Shattuck et al., 2012). Nearly 1 in 4 active-duty military members have showed signs of a mental health condition, with the rate of posttraumatic stress disorder being 15 times higher than in civilian populations (Kessler et al., 2014). The national childhood obesity rate among 2- to 19-year- olds is 18.5% (The State of Childhood Obesity, 2017). In a recent American Well (a telemedicine technology provider) poll of 4,000 respondents, 65% said they were interested in seeing their primary care physician (PCP) over video. Parents of children younger than 18 had a 74% interest in seeing their PCP through telehealth technology (Landi, 2017). Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.007 69 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Creating a Business in an Emerging Practice Area CHAPTER Ingrid M. Kanics, OTR/L, FAOTA 7 LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ Define emerging practice area in the field of occupational therapy, Describe current emerging practice areas in occupational therapy, Describe the process of creating an emerging practice business, Identify mentors for an emerging practice, and Create a plan to sustain an emerging practice. KEY TERMS AND CONCEPTS • • • • • Business goals Business model canvas Business plan Emerging areas of practice Evidence review • • • • OVERVIEW T • • • • Formal evaluation Informal evaluation Lean startup plan Mentors hroughout its history, the occupational therapy profession has always responded to the emerging needs of society. From treating the vast number of returning servicemen of World War I to supporting the growing number of children in neonatal intensive care units today, occupational therapy practitioners have been there to address these ever- changing needs. Occupational therapy practitioners have the opportunity to work with people where they live, from their houses to museums, airplanes, and community centers, and are continually adapting their practice areas to meet the continuously growing needs of society. Emerging areas of practice, sometimes referred to as nontraditional practice areas, are areas in which the occupational therapy role has not been established (Overton et al., 2009). In 2011, as part of the American Occupational Therapy Association’s (AOTA) Centennial Vision process, emerging practice areas in occupational therapy were identified (see Exhibit 7.1). Many areas of opportunity are available to occupational therapy practitioners to practice with various populations. Needs assessment Potential partner SMART method Traditional business plan Some examples of societal trends that are creating new areas for occupational therapy practice include the following: ■ The worldwide population of individuals ages 60 years or ■ ■ ■ ■ older currently is 901 million, with the number projected to reach nearly 2.1 billion by 2050 (Barratt, 2017). More than 50% of youth with autism who had left high school in the past 2 years had no participation in employment or education (Shattuck et al., 2012). Nearly 1 in 4 active-duty military members have showed signs of a mental health condition, with the rate of posttraumatic stress disorder being 15 times higher than in civilian populations (Kessler et al., 2014). The national childhood obesity rate among 2- to 19-year- olds is 18.5% (The State of Childhood Obesity, 2017). In a recent American Well (a telemedicine technology provider) poll of 4,000 respondents, 65% said they were interested in seeing their primary care physician (PCP) over video. Parents of children younger than 18 had a 74% interest in seeing their PCP through telehealth technology (Landi, 2017). Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.007 69 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 70 SECTION I. Foundations of Occupational Therapy Leadership and Management EXHIBIT 7.1. AOTA-Defined Emerging Practice Areas ■ Children and Youth ■ Broader scope in schools ■ Bullying ■ Childhood obesity ■ Driving for teens ■ Transitions for older youths ■ Health and Wellness ■ Chronic disease management ■ Obesity ■ Prevention ■ Mental Health ■ Depression ■ Recovery and peer support model ■ Sensory approaches to mental health ■ Veterans and wounded warriors’ mental health ■ Productive Aging ■ Aging in place and home modification ■ Low vision ■ Community mobility and older drivers ■ Rehabilitation, Disability, and Participation ■ Autism in adults ■ Cancer care and oncology ■ Hand transplants and bionic limbs ■ New technology for rehabilitation ■ Telehealth ■ Veteran and wounded warrior care ■ Work and Industry ■ Aging workforce ■ New technology at work ■ Education ■ Distance learning ■ Reentry to the profession Source. Adapted from Yamkovenko (2011). Copyright © 2011 by the American Occupational Therapy Association. Used with permission. All of these are areas where occupational therapy practitioners can provide services because occupational therapy has something to offer in every aspect of daily life. Although many positions are available within traditional medical settings, the future of occupational therapy lies in its continued response to helping people engage in their daily needs. This chapter provides tools to identify community-based areas of need that occupational therapy practitioners can address and a template for creating a plan to develop a business to address this need, allowing others to see how occupational therapy can touch many areas of community. Learning Activity Explore the emerging practice areas defined by AOTA in greater detail by visiting https://www.aota.org/Practice/Manage/Niche.aspx and identifying which of these niche practice areas are of interest to you. ESSENTIAL CONSIDERATIONS Start With an Idea Although AOTA has defined some emerging practice areas (see Exhibit 7.1), it is important to realize that these areas will continue to evolve as society’s needs change. An occupational therapy practitioner who is involved in a community activity that they enjoy might also see an opportunity to bring their occupational therapy skills to this activity to enable others to fully engage and participate. For example, a clinician who does pottery as a hobby may have noticed several seniors, who love doing this activity, now need additional supports after a lengthy illness. Combining occupational therapy skills with the knowledge of making pottery can help to create adaptations that allow these seniors to fully engage in this experience. The opportunities for creating a business around an emerging practice can come from many areas of the community as well as the occupational therapy practitioner’s own skills and interests. The key is to match the practitioners’ knowledge, talents, and interests with an unmet community need. This process can include nonwork interests, such as those tied to hobbies, health and wellness, or family activities. Community needs can come in many forms. They can be designing a better way for people to get around town, creating care opportunities for young children and seniors, or developing after-school programs that foster community service for teens. What is important is to be open to possibilities of how occupational therapy can meet a need in nontraditional settings. Learning Activity On a flipchart, writing board, or piece of paper, brainstorm ideas of activities that you enjoy and with which you could utilize your occupational therapy skills. These could be connected to hobbies, new ideas related to your current work, or areas that you would like to try for yourself. Next, create a list of unmet community needs. You may want to do this in a group or with a mentor. This is the brainstorming stage, so there should be no judgments put on the list that you create. Once both of these lists have been generated, look for common threads or themes that might help to identify an emerging area of practice. Needs Assessment It is important to do a full needs assessment of the emerging practice area, which is a systematic process of exploring and addressing an area of need in the community. This assessment should be progressively completed on several levels, starting with an informal evaluation followed by a formal evaluation and an evidence review. Informal evaluation Informal evaluation, or casual discussions with community members to get a feel for whether a trend one has noticed is Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 7. Creating a Business in an Emerging Practice Area being noticed or expressed by others who might work in this area, determines a gap in an individual, group, or community need. This can be a physical, emotional, or psychosocial need. Learning Activity Use the SBA marketing and trends resources (https://bit.ly/2yHKRK7) to explore one of the populations of needs that you identified on your brainstorming list. Are there any trends that appear around that population? For example, data on the employment of young adults with autism can be explored using the employment statistics found on the SBA site. Formal evaluation If the informal evaluation indicates that a need might be unmet, then a formal evaluation should be done to determine if the gap really exists and to identify any individual, group, or organization that is working to meet this need. Unlike an informal evaluation, which involves casual conversations, a formal evaluation is a formalized process of setting up focus groups, surveys, and interviews with specifically defined questions to address the gap that is has been identified. In some cases, a community partner that the occupational therapy practitioner can work with is identified to address this unmet community need. In this way, practitioners do not have to “reinvent the wheel” but can bring their skills and distinct value to an organization that is already working to address the identified community resource. Evidence review An evidence review can provide a larger picture of occupational therapy practitioners and organizations that might be trying to address the identified community need in another region of the country or the world. This information can provide occupational therapy practitioners with the resources on models that have been tried to meet the need and any outcomes that have been achieved. This type of assessment may result in acknowledging the need and showing that there are few programs addressing it. This can be an effective way to identify the need for a program to address the community need. Data can be gathered in various ways during a formal needs assessment (University of Minnesota, n.d.), such as ■ Attending or holding community meetings with those who are in need; ■ Creating focus groups to get more detailed information from specific groups within the community; ■ Interviewing key community members to get firsthand ■ ■ definitions of issues and needs; Creating a survey that can be used in an online, mailed, or in-person format; and Using the free marketing data and trends resources that are available on the U.S. Small Business Administration (SBA) website (www.sba.gov) to better understand other organizations that might be working to address the identified community need. This information will help identify other organizations that could become resources or are competitors. If no businesses are addressing this need, this fact may provide further confirmation that the emerging practice business would meet an unmet need in the community. All the information gathered during the needs assessment should be finalized and organized before looking for potential funding sources and considering creating a business around the identified emerging practice area (Cameron & Luvisi, 2012). 71 Find Mentors While conducting a needs assessment of the community, occupational therapy practitioners will find it helpful to connect with 1 or 2 mentors. These mentors should be people who know the occupational therapy practitioner well and can help them both sift through the data collected and assess their own skills and talents and how these can be used to meet the identified community need. The occupational therapy practitioner may also look for a mentor in the emerging practice area. For example, a practitioner who is looking to create a business that involves environmental modification in museums might want to identify a designer or architect who can help them navigate the world of design in museums. Such a mentor can help the practitioner understand the terminology and processes involved to be successful in an emerging practice of environmental modification in museums. Mentors can provide much more than just a listening ear. Occupational therapy practitioners going into an emerging practice area should consider a mentor for these reasons (Eugenio, 2016): ■ To gain experience not found in books or on the Inter■ ■ ■ ■ net. A mentor can share knowledge based on real-life experiences. To increase the chances of success. A mentor provides ongoing direction and timely advice on real-life business issues. To develop relationships. A mentor provides networking opportunities and has connections that can help address business needs. To have an ally. A mentor provides reassurance and encouragement at all stages of business development, especially during difficult times. To grow. A mentor can help strengthen one’s emotional intelligence, allowing one to better weather the ups and downs of running a business. Occupational therapy practitioners can have different types of mentors. Some can be more occupational therapy–based, whereas others can provide financial and business structure guidance. Still others can provide specific knowledge and skills to help practitioners meet the needs of the community members the emerging practice business is trying to address. Regardless, one should never try to enter into any business venture without at least 1 mentor to help in the process. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 72 SECTION I. Foundations of Occupational Therapy Leadership and Management Learning Activity Write down the names of potential mentors for your emerging practice business and how they could help you. Include a list of occupational therapy practitioners and others, as well as a list of skills you might need but do not have a current mentor to provide. Brainstorm a list of where you might find people with these skills. Identify Potential Partners During the needs assessment process, the occupational therapy practitioner may discover 1 or more community organizations either working with the community in need in a different capacity or running a program similar to what the practitioner wants to create. In either case, this organization could become a potential partner for the emerging practice business. The organization could be a resource for referrals to the program or may be open to hiring the practitioner to design and run the program as part of its services. A key consideration when looking for potential partners is to be sure that the emerging practice business’s vision, mission, and philosophy and the partner’s vision, mission, and philosophy are aligned in a way that will benefit all involved—the community in need, the organization, and the occupational therapy practitioner. It takes time to get to know an organization, so consider running a trial version of the program with the organization to see if a longer term relationship will work for everyone involved. Learning Activity Based on the brainstorming from your previous activity, identify community organizations that might provide programs or work with the community in need. This may involve conducting an Internet search to see if such organizations exist and what services they provide to your target population. For example, what organizations run programs to help young adults with autism transition into the workplace? Review Questions 1. Which topics are possible emerging practice areas? a. Home health b. School mental health program c. Telehealth d. Outpatient hand therapy e. Evaluation of business offices for universal access f. Neonatal intensive care unit 2. Which process is not part of the formal evaluation ­process? a. Reviewing evidence literature b. Engaging in casual conversations c. Setting up formal focus groups with clearly defined questions d. Identifying community partners who work to meet the unmet community need 3. Which of the following are reasons why an occupational therapy should consider having a mentor? a. Success is more likely with a mentor. b. Mentors will help you develop a stronger emotional intelligence to ensure you can handle the ups and downs of running a business. c. Mentors can share knowledge based on real-life experience. d. All of the above PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Develop Business Goals An important part of creating an emerging practice is to clearly define goals for the business and the programs provided to the community in need. Business goals describe what one expects to accomplish with in a company over specific periods of time, often defined as 1 year, 5 years, or 10 years. The SMART method promotes specific, measurable, achievable, relevant, and time-bound program and business goals. Any program and business in an emerging practice area should be contributing to best practices for the broader occupational therapy profession, which is facilitated by having clear, measurable goals. Learning Activity Use the SMART method to write a goal for a program that your emerging practice business will provide for your community group in need: S - Specific M - Measurable A - Achievable R - Relevant T - Time bound Hypothetical example: This business will operate an 8-week, occupation-based community employment skills group for young adults with autism that will increase employment rates by 30% (based on local demographic employment data for young adults with autism). Write at least 1 long-term goal and 2 short-term goals/objectives for your new emerging practice business. Source. Adapted from Smart Goals Guide (2016). Create a Business Plan An emerging practice business involves creating a business plan to guide the occupational therapy practitioner in building and running the business. This plan includes goals as well as the steps the business will take to achieve these goals. It will include programs offered, how they will be marketed, and how the success of these programs will be evaluated. It also should include specifics on financials and daily operational processes. A vast array of tools and organizations can Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 7. Creating a Business in an Emerging Practice Area be used to create a business plan. SBA recommends 2 different formats to create such a plan: (1) the traditional business plan and (2) the lean startup plan. Traditional business plan A traditional business plan is detailed and comprehensive, requiring a good deal of time to write. This is the plan the lenders and investors will often request when an occupational therapy practitioner is seeking financing. The traditional business plan includes the elements discussed in this section. Not all elements need to be included, but be sure to include the ones that make sense for the business being design (SBA, n.d.): 1. Executive summary—The “what” and “why” of the company, which includes a mission statement, services provided, leadership, location, financial information, and projected growth. 2. Company description—Detailed information about the company, including the need it is designed to address, the population to be served, and its competitive advantage. 3. Market analysis—Describes the size of the market, customer segments and buying patterns, competition, and barriers to entry. All the needs assessment data collected earlier in the process fit in this area. 4. Organizational structure and management of the ­business—How the company is structured and who will run it. The legal structure of the business can include a corporation, general partnership, limited partnership, sole proprietorship, or limited liability corporation. 5. Services provided/product line—Includes a description of the services or products that the business will provide and the benefits to the community in need. This should include intellectual property, copyright and patents, and research and development on the services and products. 6. Marketing and sales—Includes the plan to reach the community in need, such as various strategies and how the services will be delivered. 7. Funding requests or grants—Contains information about the business goals and the next 5-year financial plan. All debt and equity are shared in this part of the business plan. 8. Financial projections—Builds on the funding request and details income projections, cash flow, and expenses for the next 5 years. 9. Appendix—Includes all supporting documents, such as credit histories, licenses, permits, and other legal documents. 73 Lean startup plan: Business model canvas Before creating a full traditional business plan, it can be helpful to create a lean startup plan. This plan is highly focused, usually fast to write, and contains only key elements. Some lenders and investors will not find this type of plan to be enough information, but it can be a good way to conceptualize an emerging practice business (SBA, n.d.). A lean startup plan involves creating a more visual representation of what the emerging practice business will look like. The business model canvas created by Alex Osterwalder is one of the oldest and most well-known examples. Its visual format is easy to work with, and its free template allows this tool to be replicated and modified, so it is included in this chapter for readers’ use. Many additional tools are available online for free from Strategyzer (https:// bit.ly/2erkmON). The business model canvas also includes 9 components, many of which align with occupational concepts (SBA, n.d.): 1. Key partners—Include community partners, suppliers, and strategic partners who will work with the emerging practice. 2. Key activities—Include the ways the business will gain a competitive advantage through the services the emerging practice will provide. 3. Key resources—Consist of all the resources that the emerging practice has to deliver the services, including staff, capital, and intellectual property. 4. Value propositions—Clear and compelling statements about the unique value that the emerging practice brings to the community. 5. Customer relationships—Describe how the emerging practice will interact with the community in need and include in-person and online interactions from start to finish of services. 6. Customer segments—Identify the community in need that the emerging practice is trying to address. 7. Channels—List different ways through which the emerging practice will communicate with the community members in need. 8. Cost structure—List the types and proportions of fixed and variable costs for the emerging practice business and how the business will maximize value and reduce costs. 9. Revenue streams—Explain how the company will actually make money and include all the revenue streams for the emerging practice business. Learning Activity Learning Activity Explore the tools and examples of traditional business plans provided on SBA’s website at https://bit.ly/2wtW93k. Consider how you would use this website to create your emerging practice traditional business plan. Print the business model canvas free template (https://bit.ly/2erkmON). Pick an emerging practice area from the ideas that were generated as part of your earlier brainstorming, and complete the business model. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 74 SECTION I. Foundations of Occupational Therapy Leadership and Management CASE EXAMPLE 7.1. Allison: An Occupational Therapy Twist on a Travel Business Allison is an occupational therapy practitioner who has been in practice for 5 years. She has spent her entire occupational therapy career working in a local orthopedic hospital seeing many patients who have had hip, knee, and ankle surgery. On the side, she continues to help her parents run their travel business. Recently, Allison’s parents have begun to talk about retiring and have hinted that it would be great to keep the travel business in the family. This got Allison thinking about how she could combine her occupational therapy skills and her family travel business. Allison loves to travel and taking over the business is attractive to her, but she loves being an occupational therapy practitioner as well. Allison thought about her current occupational therapy clients and realized that many of them were fairly healthy seniors who also enjoyed traveling but might need a few supports when they travel because of medical issues. She did some research on travel programs for seniors and what types of adaptations and supports these programs provided. She found that this was an emerging area of tourism that she was perfectly aligned to jump into, because she understood the travel industry quite well and knew that she could use her occupational therapy skills to help design travel supports to ensure a quality travel experience for those with medical conditions that might limit their chances to travel. Allison talked with 1 of her occupational therapy mentors to share her ideas and create an overall plan for inclusive travel. She also discussed with her parents about how she could continue the family business with a new twist of making it more inclusive for potential clients of varying abilities, thus creating a marketing advantage for the business as it went forward. With her parents’ help, Allison was able to identify a particular travel experience partner that would be open to adapt its current travel packages to make it more accessible to people of varying abilities. Allison helped with onsite environmental modifications and provided the staff with some disability awareness training. They ran the 1-week-long adaptive travel experience once a month for 3 months, and Allison made slight modifications to the experience each time to ensure the program met the needs of travelers. The travel partner was so happy with the results that it asked Allison to help modify their other travel experiences to make them more inclusive as well. Allison’s parents were also happy with where they saw their business going and continue to work with Allison to make the business grow in inclusive travel opportunities. Review Questions 1. 2. 3. List the key activities that Allison is bringing to the family business that will give her an advantage over other travel agencies. Who is Allison’s customer segment? Describe ways that Allison can reach her customer segment. CASE EXAMPLE 7.2. Megan: Creating an Inclusive Swimming Program for Children With ASD and SPD Megan has been an avid swimmer for as long as she can remember. Currently, she swims on her university swim team and is studying to become an occupational therapist. Recently, the university and Megan’s swim team hosted several community swim events for children with autism spectrum disorder (ASD) and sensory processing disorder (SPD). Megan noticed that many children seemed to respond positively to these swimming experiences, and some even expressed interest in swimming regularly. This insight made Megan wonder whether there was a way to combine her passion for swimming with her developing occupational therapy skills. She shared this insight with her mentors, her swim team coach, and one of her occupational therapy professors, and she expressed an interest in creating a regular swim program for children with ASD and SPD. She approached the community organization to see whether the families would be interested in a regular swimming program. Working with these mentors, Megan researches physical activity for these populations and created an inclusive swim program that she felt would meet the needs of those who had attended the community swimming events. She made sure that the program easily fit with the community organization’s mission. The community organization ran a trial version of Megan’s swimming program, starting with a small group of swimmers to ensure that each swimmer received the support needed. The community organization made sure to interview parents and children as part of the program to measure its impact. The trial program was a huge success, and several children joined their local swim teams while continuing to participate in Megan’s swim program. Several children with SPD talked about how swimming made them feel more focused after they had been in the swimming program for several weeks. The local community group was so happy with program’s outcome that it worked with Megan to write a grant to hire her part-time and make the program a permanent part of the programming. Upon graduating, Megan joined the community organization in a full-time position as an inclusion expert, expanding her work beyond the swimming program to bring inclusive practices to all the community programs hosted by the organization. Review Questions 1. 2. 3. Who is Megan’s customer segment? What is the value that Megan brings as an occupational therapist? Who are other community partners that Megan could consider for her swimming program? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 7. Creating a Business in an Emerging Practice Area Review Questions ACOTE STANDARDS 1. What acronym describes how to create business goals? a. SMART method b. MAKER method c. Goal Attainment Scale d. SOAP note 2. A business plan that is very detailed, takes a good deal of time to write, and is very comprehensive. This is the plan the lenders and investors will often request when looking for financing. What is this business plan called? a. Budget b. Lean startup plan c. Executive summary d. Traditional business plan 3. In the business model canvas, what term best describes the clear and compelling value that the occupational therapist feels they bring to an emerging practice? a. Channels b. Key activities c. Value proposition d. Key partners 4. One type of business plan is detailed and comprehensive and can take a good deal of time to write; this is the plan lenders and investors will often request when looking for financing. What is this plan called? a. Budget b. Lean startup plan c. Executive summary d. Traditional business plan This chapter addresses the following ACOTE Standards: SUMMARY Occupational therapy practitioners have the ability to assess community needs and step in to provide solutions for the ever-changing challenges found in the world today. While being an innovator in occupational therapy practice can be exciting, it is important to take time to research and develop a business plan for the emerging practice that will reduce anxiety of “stepping out of the box” and ensure that the business will be successful. It is also important to clearly identify the needs and the community partners who can be part of the solution. Embracing mentors in occupational therapy and other fields that connect with the business concept is important to the development and ongoing growth and evaluation of the business. Clearly defined goals help with the creation of a business plan, and occupational therapy practitioners should take advantage of the many resources available to create a solid business plan. Taking the time to develop all of these components will result in the operation of an innovative occupational therapy practice that will meet community needs and expand the reach of occupational therapy around the world. Case Examples 7.1 and 7.2 describe starting a business in a new area. ❖ 75 ■ B.1.2. Sociocultural, Socioeconomic, Diversity Factors, ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ and Lifestyle Choices B.1.3. Social Determinants of Health B.3.6. Activity Analysis B.4.14. Community Mobility B.4.23. Effective Communication B.4.24. Effective Intraprofessional Communication B.4.25. Principles of Interprofessional Team Dynamics B.4.26. Referral to Specialists B.4.27. Community and Primary Care Programs B.5.1. Factors, Policy Issues, and Social Systems B.5.2. Advocacy B.5.3. Business Aspects of Practice B.5.6. Market the Delivery of Services B.5.7. Quality Management and Improvement B.6.2. Quantitative and Qualitative Methods B.6.3. Scholarly Reports B.6.4. Locating and Securing Grants B.7.1. Ethical Decision Making B.7.2. Professional Engagement B.7.3. Promoting Occupational Therapy B.7.4. Ongoing Professional Development B.7.5. Personal and Professional Responsibilities. REFERENCES Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi .org/10.5014/ajot.2018.72S217 Barratt, J. (2017). We are living longer than ever. But are we living better? Stat. Retrieved from https://www.statnews.com /2017/02/14/living-longer-living-better-aging/ Cameron, K. A. V., & Luvisi, J. (2012). Grants: Fulfilling dreams and needs for occupational therapy. Administration and Management Special Interest Section Quarterly, 28(1), 1–3. Eugenio, S. (2016). 7 reasons you need a mentor for entrepreneurial success. Entrepreneur. Retrieved from https://www.entrepreneur .com/article/280134 Kessler, R., Heeringa, S., Stein, M., Colpe, L. J., Fullerton, C. S., Hwang, I., . . . Ursano R. J. (2014). Thirty-day prevalence of DSM–IV mental disorders among nondeployed soldiers in the US Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry, 71, 504–513. https://doi.org/10.1001/jamapsychiatry.2014.28 Landi, H. (2017). Top ten tech trends 2017: Telehealth reaches the tipping point. Healthcare Informatics. Retrieved from https://www.healthcare-informatics.com/article/telemedicine /telehealth-reaches-tipping-point Overton, A., Clark, M., & Thomas, Y. (2009). A review of non-traditional occupational therapy practice placement education: A focus on role-­ emerging and project placements. British Journal of Occupational Therapy, 72, 294–301. https://doi.org/10.1177/030802260907200704 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 76 SECTION I. Foundations of Occupational Therapy Leadership and Management Shattuck, P., Carter Narendorf, S., Cooper, B., Sterzing, P., Wagner, M., & Lounds Taylor, J. (2012). Postsecondary education and employment among youth with an autism spectrum disorder. Pediatrics, 129(6), 1–8. https://doi.org/10.1542/peds.2011-2864 Smart Goals Guide. (2016). Smart goal setting. Retrieved from http://www.smart-goals-guide.com/smart-goal-setting.html The State of Childhood Obesity. (2017). Childhood obesity trends. Retrieved from https://stateofobesity.org/childhood-obesity-trends/ University of Minnesota. (n.d.). Conducting a needs assessment. Retrieved from https://cyfar.org/ilm_1_9 U.S. Small Business Administration. (n.d.). 10 steps to start your business. Retrieved from https://www.sba.gov/business -guide/10-steps-start-your-business/ Yamkovenko, S. (2011). The emerging niche: What’s next in your practice area? Retrieved from https://www.aota.org/Practice /Manage/Niche.aspx Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Management for Occupation-Centered Practice Debbie Amini, EdD, OTR/L, FAOTA, and Melissa Tilton, OTA, BS, COTA, ROH CHAPTER 8 LEARNING OBJECTIVES After completing this chapter, readers will be able to ■ Define and differentiate occupation-centered, occupation-based, and occupation-focused occupational therapy; ■ Describe the importance of occupation-centered practice to all stakeholders in a changing health care environment; ■ Identify organizational leadership, management, and educational strategies to assist with a paradigm shift to occupation-­centered practice; ■ Identify characteristics of successful transformational leaders; and ■ Identify barriers to change from preparatory-focused interventions to an occupation-centered paradigm in medical settings. KEY TERMS AND CONCEPTS • • • • • Change proactivity Change recipients Choosing Wisely Leadership vision Occupation-based practice ® • • • • Occupation-centered practice Occupation-focused practice Organizational change Patient-Driven Payment Model OVERVIEW T he power of occupation is often masked by its simplicity. It is intuitive and natural for humans to create, explore, build, rest, enjoy, and learn. By completing important and meaningful activities, people find a sense of fulfillment, pride, and purpose as they progress along Abraham Maslow’s hierarchy to reach self-actualization (Maslow, 1943). In other words, humans are occupational beings (Meyer, 1922). After World War II and the decline of the Industrial Age in the late 1950s, the occupational therapy profession was challenged both internally and externally to identify as a linear natural science and a medical model profession in which our tools are highly manufactured and our methods proven effective through the empirical scientific method. Those advocating for this change disregarded how the proposed shift would move us away from the original philosophies of our founders whose tools were everyday engagements and whose positive results were participation in life (West, 1984). As a profession seeking a secure identity, we are fortunate that since the early 2000s, society and the medical community • • • • Primary appraisal Secondary appraisal Triple Aim Valence have started to recognize that involvement in meaningful activities, in natural contexts and with other people, is indeed the recipe for quality of life, health, and wellness that transcends the physical body. Occupational therapy now stands ready to take on the challenge of being the go-to profession when illness, disability, context changes, work difficulties, and social and economic crises affect a person’s ability to participate in daily life activities. Occupational therapists have known for more than 100 years that occupation, otherwise thought of as “the things that you do with your time,” is not only the means to productive end results; its execution is a highly important end unto itself (Trombly, 1995). Unfortunately, although change is occurring, the acceptance of the paradigm shift from a preparatory and reductionist focus to an occupation-centered practice has not been fully realized by occupational therapy practitioners (Lamb, 2017). This chapter discusses the role of occupational therapy managers in ensuring that practitioners are not only providing beneficial interventions but are doing so in an evidence-­ supported and efficient way to provide the client with the best Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.008 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 77 Management for Occupation-Centered Practice Debbie Amini, EdD, OTR/L, FAOTA, and Melissa Tilton, OTA, BS, COTA, ROH CHAPTER 8 LEARNING OBJECTIVES After completing this chapter, readers will be able to ■ Define and differentiate occupation-centered, occupation-based, and occupation-focused occupational therapy; ■ Describe the importance of occupation-centered practice to all stakeholders in a changing health care environment; ■ Identify organizational leadership, management, and educational strategies to assist with a paradigm shift to occupation-­centered practice; ■ Identify characteristics of successful transformational leaders; and ■ Identify barriers to change from preparatory-focused interventions to an occupation-centered paradigm in medical settings. KEY TERMS AND CONCEPTS • • • • • Change proactivity Change recipients Choosing Wisely Leadership vision Occupation-based practice ® • • • • Occupation-centered practice Occupation-focused practice Organizational change Patient-Driven Payment Model OVERVIEW T he power of occupation is often masked by its simplicity. It is intuitive and natural for humans to create, explore, build, rest, enjoy, and learn. By completing important and meaningful activities, people find a sense of fulfillment, pride, and purpose as they progress along Abraham Maslow’s hierarchy to reach self-actualization (Maslow, 1943). In other words, humans are occupational beings (Meyer, 1922). After World War II and the decline of the Industrial Age in the late 1950s, the occupational therapy profession was challenged both internally and externally to identify as a linear natural science and a medical model profession in which our tools are highly manufactured and our methods proven effective through the empirical scientific method. Those advocating for this change disregarded how the proposed shift would move us away from the original philosophies of our founders whose tools were everyday engagements and whose positive results were participation in life (West, 1984). As a profession seeking a secure identity, we are fortunate that since the early 2000s, society and the medical community • • • • Primary appraisal Secondary appraisal Triple Aim Valence have started to recognize that involvement in meaningful activities, in natural contexts and with other people, is indeed the recipe for quality of life, health, and wellness that transcends the physical body. Occupational therapy now stands ready to take on the challenge of being the go-to profession when illness, disability, context changes, work difficulties, and social and economic crises affect a person’s ability to participate in daily life activities. Occupational therapists have known for more than 100 years that occupation, otherwise thought of as “the things that you do with your time,” is not only the means to productive end results; its execution is a highly important end unto itself (Trombly, 1995). Unfortunately, although change is occurring, the acceptance of the paradigm shift from a preparatory and reductionist focus to an occupation-centered practice has not been fully realized by occupational therapy practitioners (Lamb, 2017). This chapter discusses the role of occupational therapy managers in ensuring that practitioners are not only providing beneficial interventions but are doing so in an evidence-­ supported and efficient way to provide the client with the best Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.008 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 77 78 SECTION I. Foundations of Occupational Therapy Leadership and Management that occupational therapy has to offer. In addition, this chapter provides assistance in creating an occupational therapy department, clinic, or program where practitioners hold the focus of occupational participation as their distinct guiding professional tenet and harness the power of occupation as the solution to improving the lives of the clients they serve. ESSENTIAL CONSIDERATIONS Anne Fisher (2013) offers 3 conceptual terms to help us think about and integrate occupation as the core of practice. The first term, occupation centered, is the tenet of occupational therapy for which this chapter is written. In occupation-centered practice, practitioners or settings share the perspective that occupation is the central organizing lens or framework that grounds practice, education, and research (Nielson, 1998; Yerxa, 1998). To ensure that practice maintains an occupation-centered focus within the practice setting, managers or leaders must center their personal practice paradigm on occupation and hold it as the distinct difference between occupational therapy and other professions in the health care arena. In addition, all facility occupational therapy staff should become familiar with occupation-centered thinking and share a common understanding that occupation is at the core of the profession. A shared paradigm helps ensure fidelity of departmental or program client outcomes. Fisher (2013) also identifies occupation-based and occupation-­ focused as additional terms that further describe how occupation-centered occupational therapy practitioners organize their thinking and interventions around the notion of occupation. In simplest terms, occupation-based practice refers to evaluating and providing treatment interventions that are the exact, or parts of the exact, occupations targeted as the outcomes of intervention (Fisher, 2013). For example, observing a client as she makes breakfast is an occupation-­based way to evaluate cognitive and motor function. Having that client, whose goal is to return to making meals for her husband, cook a light meal is an occupation-based intervention to work on meal preparation and to improve problem-solving skills and physical endurance. Occupation-focused is similar to occupation-based practice insofar as occupation is the targeted outcome. However, occupation-focused practice also leaves room for the use of interventions that are not considered occupations but are more preparatory in nature (American Occupational Therapy Association [AOTA], 2014). In the case of occupation-focused interventions, the focus refers to the relative distance of actual participation from the intervention. In other words, does the intervention, whether an occupation, activity, or preparatory method or task, closely resemble or directly lead to the actual goal of intervention? If so, the intervention is proximally focused on occupation. However, if the intervention—which could conceivably be an unrelated occupation, activity, or task, such as playing a game of horseshoes to increase the client factor of shoulder range of motion for the goal of yard care—does not immediately or directly impact the target occupation, it is not considered proximal, and therefore the intervention is not occupation focused (Fisher, 2013). Therefore, practitioners must always have an occupation-centered lens to articulate the connection of factor-­focused interventions on occupational participation and ensure that such a connection actually exists and correlates with the outcome sought. In addition to preparatory methods and tasks, occupation-­ focused practice also allows using approaches to intervention identified in the Occupational Therapy Practice Framework: Domain and Process (OTPF–3; AOTA, 2014). These approaches are not occupations per se (i.e., education, adaptation, prevention) but are occupation centered. Although a somewhat different way of organizing practice than the OTPF–3, the occupation-­ focused concept overlies interventions and approaches in the OTPF–3 and helps solidify the notion that interventions that do not have occupational participation as their goal are not part of the occupation-­centered paradigm. An example of an appropriate occupation-centered and occupation-focused (but not occupation based) intervention is an orthotic device such as a CMC (carpometacarpal) immobilization orthosis that reduces thumb pain to allow electronic device use at work. The same would hold true for the use of a physical agent modality that could improve occupational performance such as a dynamic splint containing electrodes to stimulate muscle contractions worn during a functional activity such as dressing. AOTA Official Documents AOTA publishes several official documents that explicitly support the paradigm of occupation-centered practice from both a theoretical and a practical perspective. As mentioned previously, the OTPF–3, adopted by AOTA’s Representative Assembly, describes occupation as the core of the profession and offers the overarching outcome statement, “Achieving health, well-being, and participation in life through engagement in occupation” (AOTA, 2014, p. S4). The document supports and articulates that occupations are the means and the ends to intervention; it also identifies the domain, or areas of concern for the profession, and articulates their transactional relationship with the established process, or application, of occupational therapy as a client-centered intervention focused on occupational participation. Figure 8.1 provides a visual of the relationship of occupational therapy’s domain and its process and the overarching statement. Another AOTA document that provides the groundwork for the use of an occupation-centered lens for practice is the Standards of Practice for Occupational Therapy (AOTA, 2015), which defines the minimum expectations for occupational therapy practitioners and articulates to all stakeholders that the practice of occupational therapy means the therapeutic use of occupations (everyday life activities) with persons, groups, and populations for the purpose of participation in roles and situations in the home, school, workplace, community, or other settings. (p. 1). The Philosophical Base of Occupational Therapy (AOTA, 2017b) states that the profession is based on the belief that occupations are fundamental to health promotion and wellness, remediation or restoration, Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 8. Management for Occupation-Centered Practice FIGURE 8.1. 79 Occupational therapy domain and process. Education Social Participation Play Work Client Performance Factors Patterns Performance Skills Rest/ Sleep ADLs IADLs Leisure Source. From “Occupational Therapy Practice Framework: Domain and Process,” by the American Occupational Therapy Association. American Journal of Occupational Therapy, 2018, Vol. 68, Suppl. 1, p. S18. Copyright © 2014 by the American Occupational Therapy Association. Used with permission. health maintenance, disease and injury prevention, and compensation and adaptation. The use of occupation to promote individual, family, community, and population health is the core of occupational therapy practice, education, research, and advocacy. (p. 1). research articles appearing in AJOT that report positive outcomes through the use of high-quality studies targeting occupational therapy interventions and approaches. ■ A Model for Client-Centered, Occupation-Based Palliative These documents and others that support the occupationcentered paradigm are published in the American Journal of Occupational Therapy (AJOT), which is available to all AOTA members or by subscription at https://ajot.aota.org. Evidence Supporting an Occupation-Centered Approach to Care Being a leader in providing occupation-centered care means being familiar with the evidence, seminal and recent, that supports the efficacy and efficiency of occupation-centered occupational therapy for our clients and the health care system in general. The following annotated list is a sampling of ■ Care: A Scoping Review: This scoping review, which looked at more than 75 articles dedicated to the use of client-­ centered and occupation-based palliative care, found overwhelming support for the value and unique contribution of occupational therapy in this setting. It found that the most important role of occupational therapy is to provide interventions that focus on valued occupations with the understanding of the importance of time (from diagnosis to death) as a condition of occupation (Yeh et al., 2018). Promoting Health Through Engagement in Occupations That Maximize Food Resources: This participatory action research (PAR) project explored the potential benefit of a participant-driven, occupation-based approach to improving food security among people living in poverty. The study Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 80 ■ ■ ■ SECTION I. Foundations of Occupational Therapy Leadership and Management yielded statistically significant improvements in the ability of participants to make meals using identified food items as well as in their satisfaction and performance scores in self-identified activities related to food resource management (Schmelzer & Leto, 2018). Impact of an Activity-Based Program on Health, Quality of Life, and Occupational Performance of Women Diagnosed With Cancer: This 1-group, pretest–posttest, repeated-­ measures design used a functional health measure, a quality-­of-life measure, and an occupational performance and satisfaction measure to determine the efficacy of a 6-week activity-based program. The results of the study indicate improved occupational performance, satisfaction, and social relationships of community-living women diagnosed with cancer after the occupation-based program (Maher & Mendonca, 2018b). Effectiveness of Occupational Therapy Interventions to Enhance Occupational Performance for Adults With Alzheimer’s Disease and Related Major Neurocognitive Disorders: A Systematic Review: This systematic review yielded strong evidence for the benefits of occupation-­ based interventions in addition to error-reduction learning and physical exercise. The researchers concluded that daily occupations should be integrated into the daily routine of adults with Alzheimer’s disease to delay functional decline and enhance occupational performance (Smallfield & Heckenlaible, 2017). Impact of a 1-Week Occupation-Based Program on Pain, Fatigue, Participation, and Satisfaction in Women With Cancer Living in the Community: This prospective 1-group pretest–posttest design study recruited women living with cancer in underserved communities in urban, rural, and suburban areas. This study investigated the impact of an occupation-based program that lasted for 1 week and targeted pain, fatigue, occupational performance, and satisfaction with the participant group. Results demonstrate that this program was effective in decreasing pain and fatigue; it also improved participants’ occupational performance and satisfaction, which translated into overall improved participation in occupations (Maher & Mendonca, 2018a). Managers and leaders should remember that integrating research into occupational therapy practice is essential if the profession is to continue to grow and be recognized (Garber, 2016). We need to maintain the vitality of what occupational therapy is and the scope of interventions, and we must also lead the team along these same lines. Leaders and managers should not implement treatments that do not promote occupation-based practices, and we must proactively support those on the team who may need a refresher or change their personal paradigm to occupation-centered. Choosing Wisely® ® In 2017, AOTA embarked on a project called Choosing Wisely with the goal of identifying interventions that, despite being popular in practice, do not necessarily have supportive evidence and should therefore be strongly considered before being used with clients. Choosing Wisely is an initiative of the ABIM Foundation (American Board of Internal Medicine) that has recognized the importance of patients and health care professionals working together to ensure that health care offers evidence-based, safe, and effective options. Understanding the importance of this initiative, AOTA joined Choosing Wisely to help improve the quality and safety of occupational therapy services (AOTA, 2018b). Through a 3-step process that included outreach to AOTA stakeholders and practice experts, the association identified 5 interventions as not being good options for inclusion within an occupational therapy plan of care; none of the interventions selected are classified as occupation centered or inherently occupation based or occupation focused. The 5 recommendations are 1. Don’t provide intervention activities that are nonpurposeful (e.g., cones, pegs, shoulder arc, arm bike). Using valued activities is at the core of occupational therapy. Meaningful activities motivate, build endurance, and increase attention. 2. Don’t provide sensory-based interventions to individual children or youth without documented assessment results of difficulties processing or integrating sensory information. Sensory issues are complex, and an intervention that does not address the correct problem can be ineffective or even harmful. 3. Don’t use physical agent modalities (PAMs) without providing purposeful and occupation-based intervention activities. Using heat, cold, mechanical devices, electrotherapeutic, and other agents without incorporating a purposeful activity is not occupational therapy. 4. Don’t use pulleys for individuals with a hemiplegic shoulder. Overhead pulleys often lead to shoulder pain among stroke survivors and other individuals with hemiplegia and should be avoided. Gentler controlled range of motion exercises and activities are preferred. 5. Don’t provide cognitive-based interventions (e.g., paper-­ and-pencil tasks, table-top tasks, cognitive training software) without direct application to occupational performance. Occupational therapy interventions related to cognition should be part of an activity that is important to the person (AOTA, 2018b). Although sometimes faulted for presenting the negative side of the project findings (what not to do) instead of helping practitioners know what interventions are better to use (what to do), the Choosing Wisely document can be a useful tool to start a conversation with staff regarding their views of occupation and occupational therapy and the existent evidence and association philosophy on occupation-centered care. Reimbursement, Quality Outcomes, and Occupational Therapy Another area that supports the paradigm shift to occupation-­ centered and occupation-based practice concerns changes to health care reimbursement that began as part of the Patient Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 8. Management for Occupation-Centered Practice Protection and Affordable Care Act (ACA; P. L. 111–148) in 2010. In part, the ACA is meant to reform health care delivery to achieve the Triple Aim that includes better care, affordable care, and healthier people and communities (AOTA, 2013). One target of the Triple Aim has been the reduction of hospital readmissions. The high rate of people returning to hospitals after only a short time at home is the result of many factors such as poor medication compliance, falls, and other areas that an occupation-centered approach can address. A recent study found that increased spending on occupational therapy services in an acute care setting correlated with reduced readmissions for all conditions studied (Rogers et al., 2016). Another change planned for October 2019 concerns phasing out the Resource Utilization Group (RUG) reimbursement system and replacing it with the Patient-Driven Payment Model (PDPM). Under PDPM, skilled nursing facilities will receive payment based on the client’s characteristics regardless of the services provided, which is different from RUGs where more services meant a higher reimbursement rate (AOTA, 2018a). To allay concerns that occupational therapy will not be fully used because of lower reimbursement rates, managers need to guide practitioners to approach clients using the profession’s distinct focus on occupational and functional outcomes. Functional outcomes matter to facilities and payers because they save money for the system by ensuring that clients are safe and functional in their home environment and can receive less expensive services out of the hospital. In addition, occupational therapy practitioners must strive to achieve critical client outcomes and articulate the distinct value of occupational therapy services by carefully documenting occupation-based interventions and outcomes in the medical record (Sandhu, 2015). To this end, practitioners will see the benefit of completing an occupational profile—a part of the OTPF–3 that is required for occupational therapy evaluation coding according to the Current Procedural Terminology (American Medical Association, 2019) coding system—to assist them in identifying and documenting what areas of improvement are meaningful and motivating to the client as both outcomes and interventions (AOTA, 2018a). Organizational Change The switch to an occupation-centered care paradigm is equivalent to an organizational change where a mandate, outside the control of the everyday worker, leads to emotional, cognitive, and behavioral responses (Oreg et al., 2018). Although one may consider changing a practice paradigm to be a personal practitioner decision, the fact that reimbursement and the profession’s future are potentially at stake shifts the view from change as an option to change that must occur. When a change event such as this is on the horizon, the impact on the change recipients, the individuals or group of individuals that are affected by this change (in this case the practitioners), cannot be overstated. This impact ultimately imbues the recipient with a great deal of power to make the change a 81 success or failure. To guarantee that change is seen in a positive light and is sustained, managers must understand ■ The impact of change on practitioners, ■ How their reactions can make or break that change, ■ What needs to be done to facilitate long-term positive acceptance of the change (Oreg et al., 2018). For Additional Learning For additional learning, see ■ ■ Chapter 18, “Managing Organizational Change,” and Chapter 20, “Handling Resistance During Change.” Practitioner response to change The experience of the recipients of change has taken center stage in the world of scholarly research on the topic (Oreg et al., 2018; Ouedraogo & Ouakouak, 2018). For transformational leaders, this is good news because we can now understand the factors responsible for acceptance and nonacceptance and work to address them. The concepts that managers or leaders must understand when thinking about how practitioners are going to respond to change include ■ The notion of valence—in other words, how positively or negatively recipients respond to change; ■ The degree of activation, which describes passivity vs. ■ activity when dealing with the change (Oreg et al., 2018); and Affect vs. behavior and the cognitive appraisal process that precedes affective and behavioral responses. Oreg et al. (2018) developed a model that illustrates which combination of change concepts will lead to more positive and lasting change outcomes and which may lead to unsuccessful change. Figure 8.2 shows the 4 quadrants of change recipient response options. The lower right quadrant indicates an acceptance of change yet shows that such acceptance is done with little activation despite being relatively positive. Although a group arriving at change acceptance in this manner may seem like a win for leadership, the associated passivity may cause change to lose endurance because there is no real champion for keeping the change. Conversely, the upper right quadrant reflects positive valence and high activation—a proactive change recipient. Although sometimes overly optimistic and perhaps questioning of new ideas, practitioners in this group will likely ensure that change happens and endures. Those with high yet negative activation as noted in the upper left quadrant are resistant and will likely work to ensure that change does not occur, whereas those who fall to the bottom left quadrant will become disengaged. Disengaged and accepting recipients are sometimes difficult to discern because both groups will do little to ensure either success or failure of a change (Oreg et al., 2018). Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 82 FIGURE 8.2. SECTION I. Foundations of Occupational Therapy Leadership and Management Circumplex of change recipients’ responses to change and underlying core affect. Circumplex of Change Recipients’ Responses to Change Underlying Core Affect High activation Change resistance (stressed, angry, upset) Change proactivity (excited, elated, enthusiastic) Negative valence Positive valence Change disengagement (despaired, sad, helpless) Change acceptance (calm, relaxed, content) Low activation Source. From “An Affect-Based Model of Recipients’ Responses to Organizational Change Events,” by S. Oreg, J. M. Bartunek, G. Lee, & B. Do. Academy of Management Review, 2018, Vol. 43, p. 69. Copyright © 2018 by the Academy of Management. Used with permission. When managers are working as change leaders with a group of change recipients, creating a culture of change proactivity is the desired outcome. To accomplish this goal, managers must understand the leadership skills needed to create the positive valence and high activation that defines change proactivity. According to Folkman et al. (as cited in Oreg et al., 2018), the cognitive appraisal process is the key. Cognitive appraisal is undertaken by change recipients as the means of evaluating the potential impact of change events on themselves and their self-interests; resources for coping with the change event are also taken into consideration. According to Oreg et al., the outcome of the cognitive appraisal process leads to the affective and behavioral responses the recipient experiences; these outcomes are identified as accepting, disengaged, proactive, or resistant. As seen in Figure 8.3, primary appraisal is where a recipient determines the change relevance and significance to themselves and the degree to which the change is relevant to their goals—both personal and organizational. Secondary appraisal, according to Moors et al. (as cited in Oreg et al., 2018), refers to the recipient’s control or power—their belief in their ability to cope with the change (i.e., coping potential). The outcomes of primary and secondary appraisal influence both activation and valence, hence yielding the recipient response to change. In the case of activation, a combination of positive coping potential and high goal relevance leads to a recipient who is highly activated—the activation can be positive or negative depending on the perceived impact on them personally or on their organization. In other words, high coping potential, high relevance, and high congruence lead to a proactive recipient, whereas low coping, low relevance, and low congruence lead to disengagement. Acceptance in this model is a product of high congruence but low coping potential and low relevance, with resistance being brought on by high coping and high relevance but low congruence. Leadership for Change A transformational leader will be interested in gaining buy-in from the staff to accept the switch to occupation-centered practice and a commitment to work at it to get the expected client outcomes. According to Figure 8.2, the predictor criteria for adoption of the new practice are changeable factors that are potentially under the leader’s control. Attention to these factors and a concerted effort to ensure that they positively support staff coping potential, goal relevance, and goal congruence can facilitate a proactive attitude toward change in the change recipients. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 83 CHAPTER 8. Management for Occupation-Centered Practice FIGURE 8.3. Model of responses to change. Predictor criteria Factors that impact perceived support and control Coping potential Secondary appraisal Response activation Factors that decrease psychological distance Factors that impact recipients’ perceptions that their interests are considered (+) Goal relevance Goal congruence Primary appraisal Personal Change Change resistance proactivity Response valence (–) Organizational Change Change disengage- acceptance ment (+) (–) Source. From “An Affect-Based Model of Recipients’ Responses to Organizational Change Events,” by S. Oreg, J. M. Bartunek, G. Lee, & B. Do. Academy of Management Review, 2018, Vol. 43, p. 79. Copyright © 2018 by the Academy of Management. Used with permission. For example, if a leader creates a work environment where staff feels empowered and in control of elements of their workplace; where the psychological distance of the change is not seen as too far from them personally; and where the “what’s in it for me?” question is acknowledged and answered in the positive, it is reasonable to assume that the recipients of change will become champions of that change. Leadership Characteristics and Skills Supporting Change Understanding the recipient’s needs is necessary to identify which leadership characteristics and skills can address these needs. According to a model created by John Kotter in 1996, there are 8 steps to leading successful organizational change. In order of occurrence, these steps are 1. Establish a sense of urgency, 2. Create a guiding coalition of people who share a similar belief in the change, 3. Develop a vision and strategy to help break through the status quo, 4. Communicate the change vision, 5. Empower recipients for broad-based action, 6. Generate short-term wins to build credibility needed for sustained change efforts, 7. Consolidate gains and produce more change to prevent premature victory declarations, and 8. Anchor new approaches in the culture so new practices can grow deep roots. In 2018, Seijts and Gandz published a leader character framework based on research with more than 2,500 leaders from across the world. This framework identifies 11 dimensions of leadership that affect the outcome of organizational change efforts (Seijts & Gandz, 2018): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Judgment, Transcendence, Drive, Collaboration, Humanity, Humility, Temperance, Integrity, Justice, Accountability, and Courage. These character dimensions can be linked to the 8 stages of Kotter’s model to further operationalize and pinpoint leader skills and attributes that must be present for each stage of Kotter’s model to be effective. According to Seijts and Gandz, not all dimensions are necessarily incorporated into each step of Kotter’s change process, but all are needed to reach the last step of anchoring of new approaches in the culture (Kotter, 1996). To better understand the relationship of leader skills and character dimensions to proactivity in change recipients, we can look to the predictors of change elements in Figure 8.2 that identify the aspects of the environment that affect the Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 84 SECTION I. Foundations of Occupational Therapy Leadership and Management outcomes of the appraisal process (Oreg et al., 2018). Although the figure is not organized as a step continuum and does not explicitly list the leader characteristics described by Seijts and Gandz, the end result of anchoring the new approach into the culture for a sustained period of time is the implicit goal; it requires all of the character dimensions to be present within the leader during the appraisal of the change event. For example, to address the predictor of change that speaks to the practitioners’ needed sense of support and control leading to positive activation, the leader must possess transcendence, courage, justice, integrity, humility, humanity, and collaboration. Each of these provides a sense of security, consistency, fairness, and trust that are cornerstones for the perception that coping will be possible during the time of change. The leader’s ability to minimize the sense of psychological distance of the change will also require accountability, temperance, transcendence, collaboration, integrity, and judgment. The recipients must trust that the goal of the change is relevant and in their best interest before they will willingly support it. Finally, the leader must possess the character dimensions of drive, temperance, humanity, and collaboration to create trust in the fact that the change will positively impact the recipients, their organization, and ultimately their clients. When a transformational leader asks recipients of change to make real and lasting change efforts, they must draw on soft skills, including communication, attitudes, and trust (Ouedraogo & Ouakouak, 2018). A hard approach to organizational change that includes economic incentives or disincentives, restructuring, or downsizing often fails to create effective or lasting change, and instead leads to resistance or passive acceptance that sets the change on a course to failure (Ouedraogo & Ouakouak, 2018). Review Questions 1. What is occupation-centered practice? 2. What is an example of occupation-focused practice? What makes it occupation-focused? 3. What is the overarching outcome of occupational therapy as described in the OTPF–3? What does it say regarding occupation-centered practice? PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Strategies for Change to the Occupation-Centered Paradigm Beyond a manager gaining the 11 personality dimensions of a successful transformational leader, strategies that directly affect the appraisal process for paradigm change to an occupation-­ centered practice include building a culture of communication, knowledge sharing, and organizational learning that leads to interpersonal trust (Ouedraogo & Ouakouak, 2018; Park & Kim, 2018). Managers and leaders must help practitioners overcome resistance and motivate them to devote the efforts needed for the success of the change (Ouedraogo & Ouakouak, 2018). Communication allows for the deconstruction of old habits and routines and the creation of new ones as organizational change leads to differentiation from the past. To assist practitioners in changing their practice paradigm, the leader must provide ample opportunities for communication within the department; this can be in the form of team meetings and 1:1 discussions. Differentiation of the past from the future can be accomplished through discussions and by sharing current practice beliefs and those of occupation-centered thinking. As described earlier, many tools are available to the leader, including the OTPF–3, other official AOTA documents, research articles, Choosing Wisely materials, and information about changes to documentation and reimbursement; all of these set a vision of the future post-change. Discussions of cases and the creation of future-focused scenarios are ways to communicate the possible impact of change. Communication also allows the leader to hear feedback, accept assistance, and gather ideas from practitioners as they become an active part of the change process. Skilled leaders, using their personal characteristics of collaboration, humanity, humility, transcendence, and integrity, will facilitate this open and honest dialogue (Seijts & Gandz, 2018). Allowing organizational silence, driven by the leader’s fear of letting people share dissenting opinions or potentially creating disagreements within a department, is one of the most detrimental things leaders and managers can do when attempting to build trust (Park & Kim, 2018). The messaging and discussions surrounding change to a new intervention paradigm must be honest and consistent over time. Such consistency not only builds a common vision for the future of the department, but it also builds trust between the leader and the practitioners and among the practitioners themselves. Role modeling and being a champion for occupation-centered practice will also go a long way to build trust. To be successful with this tactic, managers must know their own sentiments about change and make them known to staff. Additionally, change recipients need to know when, how, and by whom the change will be implemented; they also want details about what is expected of them, including the potential risks and benefits for themselves, the department, and the profession. Communication and trust lead to a sense of shared purpose and camaraderie that increase trust and communication (Park & Kim, 2018). To facilitate knowledge sharing and a culture of learning in an occupational therapy department, managers must demonstrate good judgment, drive, and courage to ensure that practitioners learn how occupation-centered therapy works, what challenges and rewards are likely, and how to document to support our distinct value. Managers must also provide resources that practitioners can use in their own learning and share with each other. For example, a leader should work with upper management to provide AOTA membership for those who are not members. Attendance at conferences and workshops and participation in continuing education programs that support the new paradigm should be funded or strongly encouraged. It should be noted that change and transition can take time; managers and leaders must not be discouraged by the fact that developing habits through the diffusion of new knowledge is a slow and tedious process (Garber, 2016). Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 8. Management for Occupation-Centered Practice Developing a Personal Leadership Vision As an occupational therapy practitioner, a transformational leader needs to have a personal leadership vision and plan. Why is it necessary to have a personal leadership vision? A leadership vision represents an ideal future state and guides the organization toward a higher standard of excellence. Our profession has resources, workshops, and conferences to help us, but we must put it into practice. Identifying that we need to lead with occupation-based practice is the first step, and it should be followed by identifying a vision where we can see ourselves doing just that. Putting occupation-­based practice on paper as a goal, or a vision, will help identify areas in which one might need more training or support and areas in which one can share successes with others. For Additional Learning For additional learning, see Chapter 1, “Theories of Leadership.” CASE EXAMPLE 8.1. A leader will first identify what kind of leader they want to be and then identify a vision statement, which will help guide the chosen leadership style. Sharing the vision with the team will begin a dialogue about the change in which the staff learns from the leader and the leader learns from the staff. The team may be encouraged to develop a department leadership statement and tie it back to the vision and mission of the organization and the profession. Review Questions 1. Beyond the 11 important character dimensions of a transformational leader, what other leader qualities are important in an environment of organizational change? 2. A forward-facing vision in which the past is in the past is essential for success of organizational change. How can a leader assist staff in separating from past methods of occupational therapy intervention? 3. What types of resources should a transformational leader provide or suggest to staff that are going through a change in practice paradigm? New Manager and a Paradigm Shift Raphael, a new rehabilitation manager at a long-term care facility, walks into the occupational therapy clinic and sees occupational therapy practitioners using arm bikes, cones, and pencil-and-paper tasks while clients passively participate in their treatment sessions. Family members are observing treatment, and Raphael overhears a woman ask whether these tasks might be done at home instead of taking time off from work to drive her family member to the clinic. Raphael spends some time watching and listening to the practitioners interact with the clients. He notices a lack of enthusiasm in the practitioners’ voices when speaking with clients, and he hears comments that indicate the need for clients to complete tasks as soon as possible so the practitioner can move on to the next person. Raphael then completes a chart review and finds that several clients have recently been readmitted to the facility from the hospital after having been discharged to home due to falls. Several who had been discharged with modified independence in self-care ADLs now require moderate to maximum assist. Some charts did not have an occupational profile or any type of standard assessment to validate the selection of client factor–focused goals. This is not how Raphael was trained, and these practices do not align with his understanding of best practice occupational therapy. Raphael decides that as the department manager, he must do something to address his concerns. Raphael recognizes that change is required within this clinical setting and takes the following steps: 1. 2. 3. 4. 5. 6. 7. 8. 9. He prints out several official documents from AOTA describing occupation-centered practice and reviews them so he can share information with his staff. He sets up a time for all practitioners in the department to have lunch together so they can get to know each other. When treating his own caseload, he evaluates clients using the AOTA Occupational Profile Template (AOTA, 2017a) available from AOTA, other tools that assess client factors, and performance skills using activities. He creates a plan of care documenting client-centered and occupation-based goals. He establishes a weekly meeting with the entire staff to discuss the history and philosophy of occupational therapy and how health care changes are identifying traditional occupational therapy interventions as important for saving money. He arranges to show an AOTA regulatory webinar explaining the coming changes to reimbursement. He works with practitioners to create their personal practice philosophy. He seeks feedback and suggestions from the staff to determine the next steps to changing the paradigm of the department. He creates a vision for the department with the staff. He asks each staff member to research an aspect of occupation-based practice that should be integrated into the department and then share their findings with the rest of the staff. Review Questions 1. 2. 3. 85 How will the steps identified encourage practitioner buy-in to change vs. resistance to change? How does realigning treatment with occupation-based practice improve quality of care? What could occur during the change to an occupation-centered paradigm if acceptance without proactivity is the manner in which the staff approaches the change? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 86 SECTION I. Foundations of Occupational Therapy Leadership and Management SUMMARY This chapter reviewed the value and importance of occupation-centered practice as well as the supportive literature. As the profession distinctly focused on ensuring that clients can engage in purposeful and meaningful activities, managers must transition from current client factor–focused intervention to an occupation-centered paradigm; they must also encourage practitioners to adopt this new paradigm. Case Example 8.1 describes realigning to occupation-based practice. To gain acceptance and lasting change of the new paradigm, transformational leaders must use their leadership skills and communication abilities to establish trust and develop a work culture that has a shared vision and shared appreciation of learning. Practitioners who demonstrate change proactivity—who are affectively interested in the change and behaviorally motivated by the change—will ensure a positive outcome. ❖ LEARNING ACTIVITIES 1. Develop a personal philosophy of occupational therapy and a leadership vision. 2. Identify the skills and attributes that define the leadership dimensions as described by Seijts and Gandz (2018). 3. Review the documents identified in this chapter that support occupation-centered practice. 4. Create a list of opportunities and challenges to adopting an occupation-centered paradigm that are specific to your setting; share this list and elicit feedback from the occupational therapy staff. 5. Work with the staff to create an educational experience for your facility to highlight the distinct value of occupational therapy. ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ B.5.2. Advocacy ■ B.5.7. Quality Management and Improvement ■ B.7.3. Promote Occupational Therapy. REFERENCES Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. 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Impact of an activity-based program on health, quality of life, and occupational performance of women diagnosed with cancer. American Journal of Occupational Therapy, 72, 7202205040. https://doi.org/10.5014/ajot.2018.023663 Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370–396. https://doi.org/10.1037/h0054346 Meyer, A. (1922). The philosophy of occupational therapy. Archives of Occupational Therapy, 1, 1–10. Nielson, C. (1998). How Can the academic culture move toward occupation-centered education? American Journal of Occupational Therapy, 52(5), 386–387. https://doi.org/10.5014/ajot.52.5.386 Oreg, S., Bartunek, J. M., Lee, G., & Do, B. (2018). An affect-based model of recipients’ responses to organizational change events. Academy of Management Review, 43(1), 65–86. https://doi.org /10.5465/amr.2014.0335 Ouedraogo, N., & Ouakouak, M. L. (2018). Impacts of personal trust, communication, and affective commitment on change success. Journal of Organizational Change Management, 31(3), 676–696. https://doi.org/10.1108/jocm-09-2016-0175 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 8. Management for Occupation-Centered Practice Park, S., & Kim, E. (2018). Fostering organizational learning through leadership and knowledge sharing. Journal of Knowledge Management, 22(6), 1408–1423. https://doi.org/10.1108/jkm-10-2017-0467 Patient Protection and Affordable Care Act, Pub. L. 111-148, 42 U.S.C. §§ 18001–18121 (2010). Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2016). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 74, 668–686. https://doi.org/10.1177/1077558716666981 Sandhu, S. (2015). Quality: The new payment paradigm. OT Practice, 20(10), 6. Retrieved from https://www.aota.org/Advocacy-Policy /Federal-Reg-Affairs/News/2015/quality-new-paradigm.aspx Schmelzer, L., & Leto, T. (2018). Promoting health through engagement in occupations that maximize food resources. American Journal of Occupational Therapy, 72, 7204205020. https://doi.org /10.5014/ajot.2018.025866 Seijts, G. H., & Gandz, J. (2018). Transformational change and leader character. Business Horizons, 61, 239–249. https://doi.org/10.1016 /j.bushor.2017.11.005 87 Smallfield, S., & Heckenlaible, C. (2017). Effectiveness of occupational therapy interventions to enhance occupational performance for adults with Alzheimer’s disease and related major neurocognitive disorders: A systematic review. American Journal of Occupational Therapy, 71, 7105180010. https://doi.org/10.5014 /ajot.2017.024752 Trombly, C. A. (1995). Occupation: Purposefulness and meaningfulness as therapeutic mechanisms. American Journal of Occupational Therapy, 49, 960–972. https://doi.org/10.5014/ajot.49.10.960 West, W. L. (1984). A reaffirmed philosophy and practice of occupational therapy for the 1980s. American Journal of Occupational Therapy, 38, 15–23. https://doi.org/10.5014/ajot.38.1.15 Yeh, H., McColl, M. A., & Huang, L. (2018). A model for client-­ centered, occupation-based palliative care: A scoping review. American Journal of Occupational Therapy, 72, 7211505084. https://doi.org/10.5014/ajot.2018.72s1-po1015 Yerxa, E. J. (1998). Occupation: The keystone of a curriculum for a self-defined profession. American Journal of Occupational Therapy, 52, 365–372. https://doi.org/10.5014/ajot.52.5.365 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] SECTION II. Organizational Planning and Culture Edited by Judith A. Parker Kent, OTD, EdS, OTR/L, FAOTA 89 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Strategic Planning 9 L. Randy Strickland, EdD, OTR/L, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ Understand the steps in strategic planning for an organization and its stakeholders, Identify current and future use of strategic planning in both work or professional settings and in personal application, Use the SWOT analysis and scenario development processes as a base for an organization or program’s planning, and Describe varied leadership roles for the occupational therapy practitioner in strategic planning in varied settings. KEY TERMS AND CONCEPTS • • • • Mission Opportunities Scenarios Stakeholder input • • • • Strategic plan Strategic planning Strategy Strengths OVERVIEW S trategic planning is a process used by organizations to chart or map future plans and goals. An organization’s planning process results in the creation of a strategic plan, which sets the pathway for an organization’s development and success. Strategic planning considers an organization’s purpose and future aims or aspirations. The resulting strategic plan includes specific goals focused on attaining the organization’s vision. These goals are linked to objectives and strategies that provide ongoing support of its mission (Rhine, 2015). Merely setting goals is often a useless exercise unless an organization’s leaders and members commit to identifying and using strategy, or methods or activities that enable achievement of the plan’s goals. A viable and dynamic strategic plan includes the buy-in and active participation of its stakeholders and leaders. Strategic planning includes staff at all levels of an organization regardless of size and can promote personal growth for its individual members. This chapter describes the strategic planning process and its application for occupational therapy settings and practitioners. Organizations and programs serving individuals in • • • • SWOT analysis Threats Vision Weaknesses health, educational, or human services agencies are greatly influenced by social, economic, political, geographic, cultural, and technological factors. Occupational therapy practitioners, as essential service providers, researchers, educators, consultants, and community/organizational leaders, are key participants in the strategic planning processes in their specific roles and settings. Their perspective in strategic planning is a valued addition to the interdisciplinary process, which ultimately strengthens the overall results for an organization or program. Involving occupational therapy staff in strategic planning at an individual, unit, or organizational level promotes and ensures that valued occupational therapy services are recognized and available for patients and clients. ESSENTIAL CONSIDERATIONS Mission and Vision The first step in strategic planning is identifying why the organization exists. The stated purpose of an organization is referred to as its mission. The organization’s mission provides the foundation for its very existence and plans. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.009 91 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 92 SECTION II. Organizational Planning and Culture An organization’s or program’s purpose typically does not change substantially over time. For example, a pediatric outpatient clinic’s purpose might be providing community-­based developmental services, and this purpose remains a foundation of the program across time. However, the clinic’s goals and strategies may shift based on internal and external environmental changes and influences. Such shifts still affirm the mission’s necessity but also result from aspiration for a new or expanded level of achievement or contribution by the organization. This vision or aspiration states an ideal of what the organization perceives as its desired and prized benchmark of achievement. For example, the American Occupational Therapy Association (AOTA) is a professional membership organization grounded by its mission linked to its vision. AOTA’s mission is To advance occupational therapy practice, education, and research through standard setting and advocacy on behalf of its members, the profession, and the public. (AOTA, 2018, para. 6) AOTA also has a vision, Vision 2025: Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living. (AOTA, 2017, p. 1) The mission and vision of an organization are the foundational cornerstones of the strategic planning process. These statements define an organization’s purpose through setting the stage; identifying the organization’s core values; and providing guideposts for planning, goal setting, and decision making (Eber & Smith, 2015). Broad Stakeholder Participation An organization involved in the strategic planning process needs to ensure that any new or revised plans are based on a sound process. Typically, a strategic plan encompasses a relatively short time span of 3–5 years (Eber & Smith, 2015). Considerable time and staff resources are often allocated to designing a strategic plan. Most important, the strategic planning process should advance the organization. The plan should not merely become a document in a file but a viable plan to help an organization remain true to its mission and attain goals through strategies that promote its vision. A key ingredient in a successful strategic plan is broad participation of its stakeholders. Stakeholder input is key information or data collected from individuals, agencies, organizational units, and consumers who are invested in the success of the organization and its mission. Stakeholder input is important for identifying, understanding, and appreciating the multidimensional aspects of the organization’s reputation and its influence within the environmental context (Gatzert & Schmit, 2016). Stakeholder input can be categorized into varied groups, depending on the type of organization, and may include both internal and external groups. Stakeholder examples include the organization’s own staff and leadership, community advisory groups, payers and other financial groups, and, most important, the consumers or individuals the organization serves. The richness of input and active participation in both the design and implementation of a strategic plan are maximized through diverse stakeholder involvement in the process. Different opinions and perspectives enrich the strategic planning process and produce better plans more likely to succeed. Participation levels may range broadly from total immersion in the planning process to simply seeking a group’s or an individual’s review or feedback about parts of the plan. Seeking input from the bottom-up of an organization’s members rather than from a top-down management approach provides meaningful data. This broad participation ensures the likelihood of planning success and relevance to the real needs and potential of the unit or organization (Roth, 2015). Organizational communication to stakeholders about what information is used and why a strategy or goal is selected better influences the ultimate success of the strategic plan (Cervone, 2014). SWOT Analysis A strategic plan involves a systematic approach for determining needed resources to address strategic goals and help the organization achieve its vision and support the mission. Strategic planning includes thoughtful analysis of the organization’s internal and external environment. This environmental review sets the stage for better understanding the quantitative and qualitative factors influencing the organization’s day-today operations and future aspirations and goals. One widely used approach in strategic planning is a SWOT analysis. The organization often conducts the SWOT analysis over a period of time, including both internal and external stakeholders. This SWOT assessment includes identifying ■ S: Strengths—Internal assets or characteristics within the ■ ■ ■ organization or unit that enhance the organization’s capacity for growth or change; W: Weaknesses—Internal conditions or characteristics within the organization or unit that hinder or restrict the organization’s growth potential; O: Opportunities—External events or possible or current changes in the environment that may affect the organization in a potential positive capacity; and T: Threats—External actions or events—current or potential—that may cause harm to the organization’s strategic growth, well-being, and possible competitiveness. Strengths and weaknesses are those factors that characterize the organization from an internal view; opportunities and threats represent those factors that may affect the organization from outside the organization or unit (Harrison, 2016). Exhibit 9.1 provides an abbreviated SWOT analysis for adding a proposed hand rehabilitation facility at an existing branch location of an established hospital system. The SWOT analysis in Exhibit 9.1 was completed by individuals familiar with the organization or unit. Internal operations reports such as financial data, sources of physician referrals, and staffing are important data sources. External information such as competitor analysis, regulatory factors, and other external reports helps create an environmental Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 9. Strategic Planning EXHIBIT 9.1. SWOT Analysis for Proposed Hand Rehabilitation Program ■ Strength: The hospital system has an existing branch for outpatient service with unused space and 2 occupational therapy staff (both certified hand therapists) in the hospital with interest in outpatient services. ■ Weakness: The rehabilitation director recently retired, and the position is currently unfilled. ■ Opportunities: Several referring physician orthopedic practices are in the same area as the branch location. ■ Threats: A competing regional hand practice is reported to be considering adding a location in the same area. 93 The strategic plan should be focused by a comprehensive strategy that explicitly details the plans for achievement in easily understood language. The criteria for goal success must also be delineated. As the plan proceeds, the goals may be met or deemed inappropriate and requiring review or change; continuous assessment of successful strategies and goals met promotes a strategic planning model that integrates planning and outcomes measurement in a transparent manner to all stakeholders (Cervone, 2014). Successful strategic planning is not static but is a dynamic, evolving process and is closely akin to the patient evaluation process (see Figure 9.1). Review Questions analysis for the organization. This analysis leads to the formulation of the SWOT, which provides a benchmark detailing the organization’s current status and the feasibility of either beginning or refining its operations to achieve its goals and vision (Kash & Deshmukh, 2013). Scenario Identification Examining the organization’s SWOT can empower its leaders and stakeholders to begin future planning. Knowing the organization’s history and related strengths and weaknesses provides the basis for evaluating possible future actions. If the mission of an organization provides its purpose or anchor and the vision provides a future aim or aspiration, the SWOT sets the stage for considering future action and strategy. Selecting goals and strategy (the means or activity to achieve the goal) is premature without asking a series of “what-if” questions. Such questions lead to identifying scenarios that may occur given the results of the organization’s SWOT. Scenarios represent potential alternative views of the future. Strategic planning and the SWOT analysis process provide an organization with the tools to thoughtfully visualize potential desired or potentially undesirable futures. Identification of actions that may lead to more desirable future outcomes is vital for effective decision making and strategic planning (Ungerer et al., 2016). Debating the merits of multiple scenarios allows the organization to weigh varied options and select the scenario (or combination) that provides the best direction for the strategic plan. Selection may be directed toward program growth or development or toward risk reduction. The scenario leads to the development of strategies and goals, which must be measurable. Input from all levels of the organization should be used as appropriate. Strategic Goal Prioritization, Selection, and Evaluation Once the unit or organization determines its direction, developing strategic goals begins. Keep in mind that the plan’s goals are typically measurable over a 3- to 5-year period and are prioritized based on the organization’s SWOT, mission, and vision. The number of goals in a plan varies but is often 5 goals or fewer. 1. Select a nonprofit health or human services organization and review its website or other print materials. What are its stated mission and vison? How do they support each other? What similarities or differences exist between your selected organization’s vision and mission statements and those of AOTA? 2. What are key differences among the strengths (S), weaknesses (W), opportunities (O), and threats (T) in an organization’s SWOT analysis? 3. What are the key steps in the strategic planning process? 4. What are some examples of both internal and external resources that can be useful in obtaining a better environmental picture or view of an organization today and in the future? 5. Why is stakeholder participation important in the strategic planning process, and how can different groups or perspectives be facilitated and included? PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Occupational therapy practitioners may perceive that strategic planning processes do not directly affect their daily practice environments, but all occupational therapy programs are a part of some organization or system, whether the setting is a solo practitioner with a contracting practice, school-based therapy services, a therapist-owned outpatient clinic, an occupational therapy department in a freestanding facility, rehabilitation services in a skilled nursing facility (SNF), or various other settings. Occupational therapy practitioners are part of organizations that must engage in strategic planning and strategic decision making in order to remain viable, competitive, and relevant in an ever-changing service delivery system. Occupational therapy staff may be afforded the opportunity to participate in an organization’s strategic planning process. Participation may include a staff member serving as a committee member or as part of a focus group. The occupational therapy unit and its staff may be asked to review possible plans or data about the organization and the clients served (past, present, and future) and provide feedback. Most important, the occupational therapy perspective and voice can help shape an organization’s strategic plan, including its goals, strategies, and future approaches, and the allocation of financial resources. Occupational therapy’s contributions to the organization’s strategic plan can foster greater financial Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 94 SECTION II. Organizational Planning and Culture FIGURE 9.1. Strategic planning cycle. 1. Mission Review & Vision Development 2. SWOT Development and Validation 8. Plan Review/Revision 3. Possible Strategic Scenarios Review 7. Plan Evaluation 6. Strategies Identification 4. Scenario(s) Selection 5. Strategic Goals Formulation and Review Source. Adapted from “Strategic planning,” by R. Strickland, 2011, in K. Jacobs & G. L. McCormack (Eds.), The Occupational Therapy Manager (5th ed., p. 106), Bethesda, MD: AOTA Press. Copyright © 2011 by the American Occupational Therapy Association. Adapted with permission. stability or growth, the development of new or enhanced service delivery products, and support of its vision and mission. Selected key applications for occupational therapy practitioners include ■ Advocacy, ■ Advancement, and ■ Personal development and professional growth. Advocacy for Patients and Profession Occupational therapy practitioners provide identification of and voice to the needs of patients/clients and, by participating in an organization’s planning activities, can advocate for needed services, including occupational therapy. Participating in member and advocacy organizations also provides an important voice for the occupational therapy view and profession. Advancing New or Improved Services Beginning a new clinical program is often an activity occupational therapy practitioners undertake. For example, a practitioner may be asked to develop and lead a new program that supports the organization’s strategic goals. Or the occupational therapy unit may have developed its own strategic plan, including new or revised program plans, as a part of or in support of the organization’s larger plan. Whether the idea of a new or revised program or service originates in the organizational strategic plan or as a strategy in the occupational therapy unit, any new initiative must be vetted. Considering the development of a new service means revisiting and reviewing the SWOT process to determine the unit’s capacity to undertake a new initiative. Looking at costs and the return on investment certainly examines the program’s value for the targeted patient/client population. The financial and clinical evidence base of the program must be carefully documented. Timely and current evidence-based practice research is an essential part of any strategic approval of a new initiative. The vetting also needs to consider whether the new approach or protocol supports the organization’s mission or vision, and whether the organization has the resources, including qualified staffing (current or future hires), for program success. Personal Development and Professional Growth Occupational therapy practitioners usually work as part of teams in myriad organizations. The organization may be nonprofit, for profit, or even a therapist-owned proprietorship. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 95 CHAPTER 9. Strategic Planning Regardless of the work setting, the individual practitioner is part of a larger system. In turn, the organization has both an ethical and a fiduciary responsibility to ensure that all its members or employees are competently fulfilling their duties pertinent to their assigned roles. Each occupational therapy practitioner manages the delivery of occupational therapy services regardless of position title. Likewise, the practitioner’s assumption of leadership roles in professional membership or other community organization creates the stage for participation in the strategic planning and direction of those groups. The assumption of varied leadership roles is greatly expanded when occupational therapy practitioners become strategically creative in their thinking (Drenkard, 2012). Successful fulfillment of both paid (e.g., practitioner, educator, consultant, manager or administrator) and volunteer roles by occupational therapy practitioners depends on each individual’s personal and professional development. Hinojosa (2012) described the daily challenges for occupational therapy practitioners in ever-changing work settings and recommended that practitioners develop individual strategic plans for their own growth and development. Employers, professional membership organizations such as AOTA, and others also promote personal and professional development. Applying the concepts of personal strategic plan development to their lives helps practitioners to competitively prepare for ever-evolving service delivery models. Developing one’s own strategic plan and focus recognizes both the accountability and professional autonomy of each practitioner. Review Questions 1. As a member of your state occupational therapy association, what outreach steps can you undertake to influence the strategic planning of state or community agencies? How would you prioritize your actions? 2. Consider that you, as the occupational therapy supervisor, are presenting a new program idea to the administrative council of the rehabilitation hospital. What steps regarding the strategic plan of the hospital should you review prior to your presentation? Why? 3. Can you describe your own personal vision statement as an occupational therapy practitioner for the next 5 years? What specific goals and strategies are you considering to achieve your vision? CASE EXAMPLE 9.1. Mount View Hospital Transformation Mount View Hospital (MVH) is situated in a rural vacation community with a year-round population of 18,000, which more than doubles during its 3 peak tourist seasons. For more than 60 years, this locally directed nonprofit hospital has served the community and offered an emergency department, 50 acute care beds, and outpatient services, including physical therapy and labs. Twenty-five years ago, MVH issued a bond for the construction of a 60-bed SNF wing, including inpatient rehabilitation services (occupational therapy, physical therapy, and speech–language pathology); this diversification was planned to offer a new revenue stream and meet a community need for SNF services since the nearest facility was in another county. Over the past 5 years, MVH has experienced financial challenges and an annual growing budget deficit. Acute-care bed occupancy averages less than 50%; SNF occupancy has remained around 92%, but reimbursement levels, along with relatively few subacute admissions, have not supported expenditures. Outpatient services have shown a very profitable gain but are hampered by limited space. Hospital debt (both operating costs and bond debt) has been managed with a $250,000 withdrawal each of the past 3 years from the MVH endowment; this endowment will be exhausted within 5 years if no sustainable action plan occurs. MVH’s current mission statement (established at its formation 62 years ago) is MVH will provide needed hospital and medical services to the residents and visiting tourists to this community. MVH strives to offer the best possible emergency and inpatient care for the community. MVH has used multiyear operational plans for most of its existence but has not undergone a comprehensive strategic planning process with the creation of a new or renewed vision in at least 10 years. The organization has existed primarily through its endowment and generous community support. Recently, the MVH Board of Trustees and the newly appointed chief executive officer (CEO) began a strategic discussion and analysis of the organization’s long-term sustainability. As with many rural hospitals, MVH faces significant financial peril in the advent of increasing costs, decreased revenues, and shifting program needs. With support and participation of the Board of Directors, the CEO launched an organization-wide strategic planning initiative. Community advisory groups were polled regarding MVH and its services. A hospital services consulting firm conducted an analysis of MVH’s operations, collected patient satisfaction survey data, and completed a competitor analysis. Mini-SWOT meetings were conducted with all units throughout the hospital. As a result of this initiative, a draft strategic plan was prepared, and varied stakeholder groups were assigned areas for review. A summary of the draft is provided. Strategic Plan: Initial Draft for Stakeholder Input MVH Mission We will serve the Mount View residents and visitors by providing compassionate, quality health services that promote their health and well-being. (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 96 SECTION II. Organizational Planning and Culture CASE EXAMPLE 9.1. Mount View Hospital Transformation (Cont.) MVH Vision MVH will be the health provider of choice through inpatient, outpatient, and community services and will be recognized for its cost-effective, quality patient outcomes. SWOT Analysis ■ ■ ■ ■ Strengths: Community support, endowment for growth, excellent physical plant with possible expansion space, excellent physician support, excellent nursing and rehabilitation staff, and highly regarded outpatient services, including physical therapy. Weaknesses: Low acute care occupancy, SNF revenues shortfall, failure to meet budget for past 3 years, continued rising wage costs, no recent viable strategic plan, loss of 2 CEOs in last 4 years (health issue, family death). Opportunities: New orthopedic group adding branch location; new local for-profit long-term care facility offering to purchase the SNF 60 license; and regional health education center establishing cooperative to provide rural-based preservice education internships for physicians, nurses, and allied health providers. Threats: Adjacent county hospital joining national hospital chain, possible federal and state funding reductions, and increasing supply costs. Scenario Identification and Selection Possible scenario options (select items) if MVH 1. Continues to use endowment and faces possible closure within 5 years or less, 2. Reduces its operations to only outpatient services, 3. Eliminates losing units such as SNF, 4. Identifies new partnerships to decrease costs, and 5. Creates new programs. MVH has determined that Option 1 is not a responsible action. Option 2 limits the organization’s financial exposure but loses an important niche with inpatient services and the later flow into outpatient programs that are profitable. MVH is proposing that a combination of Options 3–5 may provide a better and more community-oriented approach. By further focusing its resources and programs, MVH can become financially solvent and a more valuable community asset. Selling the SNF license and the 60 beds provides SNF beds in the community by another organization whose primary business is long-term care. The existing SNF rehabilitation services staff (3 PTs and 1 PTA, 3 OTs and 1 OTA, and 2 SLPs) and outpatient physical therapy staff can develop new outpatient programs. Likewise, other hospital units can propose new or revised services. The acute care unit will be reduced to 25 inpatient beds, with 5 observation beds. Finally, MVH is developing a joint management proposal with the regional health education center and a university with its medical school’s affiliated teaching hospital system. Strategic Goals MVH has formulated 4 broad strategic goals and has requested specific units to provide comments, possible strategy statements or plans, and evaluation criteria. The 4 draft strategic goals include 1. Reduce operating deficits and achieve a balanced budget within 24 months; 2. Develop centers of excellence in select outpatient services; 3. Implement a joint management contract with the medical school’s affiliated hospital system; and 4. Streamline the acute care services, including developing its role as part of a regional referral system. Next Steps This MVH draft plan is incomplete and requires considerable input by stakeholders both within and outside the organization. One major proposal in the plan is the further development of outpatient rehabilitation services. With the closing of the SNF unit, currently employed occupational therapy and other rehabilitation staff have been asked to consider remaining with MVH and further developing the existing rehabilitation outpatient services, which currently include only physical therapy. The hospital recognizes that while the therapy services represent financial costs, an opportunity exists for developing a new center of excellence with current staff. The rehabilitation staff needs to consider several strategy items as they prepare their response to the draft document. • • • Now is the time for the rehabilitation staff to collectively prepare their input as a unit. Seeking input from others for ideas and suggestions about new programming in the outpatient arena will broaden their perspectives. On the basis of the MVH proposed scenario, the unit can complete its own internal SWOT analysis. Focusing on the range, community need, and cost–benefit analysis for varied programs will assist MVH in developing strategy and measurable, detailed goal selection. Strategy choices for Goals 2 and 3 are areas of possible high impact as brought forward through the planning efforts of the rehabilitation services team. It is often stated that the most valued and costly resource to replace for any organization is its people or staff. It is prudent for the staff’s feedback to address any needed retraining or skill acquisitions that may be desired for program success and staff investment and competency. Ultimately, MVH has both tremendous challenges and opportunities. Occupational therapy practitioners and the other rehabilitation staff can help create new sources of revenue and, most important, promote the achievement of MVH’s vision and mission. (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 9. Strategic Planning 97 CASE EXAMPLE 9.1. Mount View Hospital Transformation (Cont.) Review Questions 1. 2. 3. 4. The MVH case is similar to many other situations in the health and human service delivery systems. Often, an individual unit such as the Occupational Therapy Department does not stand alone, but collaborates with others in service delivery. What are some key factors to consider in the rehabilitation services internal SWOT analysis for the draft MVH strategic plan? How can broad participation with other disciplines support the establishment and attainment of Strategic Goals 1–4? What are the recommended new or revised rehabilitation program–specific goals and strategy steps required to support the overall MVH plan? What are the key challenges and opportunities in personal and professional development plans for the rehabilitation staff who may transition into newly designed outpatient programs? What strategies or approaches can you, as an occupational therapy practitioner, use to become an active contributor in the strategic planning process in your work position or volunteer role? SUMMARY Strategic planning creates the means for an organization to both examine its current position and chart a future course. The strategic plan is anchored by its mission and designs its future plan based on a vision or aspiration. Developing a strategic plan benefits from broad stakeholder participation, including members of the organization and interested related or community-based groups, as illustrated by Case Example 9.1. A strategic plan is based on an internal and external environmental assessment. A SWOT analysis provides the framework for gauging an organization’s current status and future potential. The SWOT analysis leads to the generation of possible scenarios that may occur in the future. Scenario selection, including the elimination of less likely ones and possible combinations of others, helps the organization in selecting and formulating goals and strategy. An ongoing cycle of evaluation and reassessment continues this process. The thoughtfully prepared strategic plan promotes strategic dialogue and thinking by an organization’s leaders and members and provides a pathway for successful growth and development. ❖ ACOTE STANDARDS This chapter addresses the following ACOTE Standards: • • • • B.5.1. Factors, Policy Issues, and Social Systems B.5.2. Advocacy B.5.3. Business Aspects of Practice B.5.6. Market the Delivery of Services. REFERENCES Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7214210005. https://10.5014 /ajot.2018.72S217 American Occupational Therapy Association. (2017). 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(2011). Strategic planning. In K. Jacobs & G. L. McCormack (Eds.), The occupational therapy manager (5th ed., pp.103–112). Bethesda, MD: AOTA Press. Ungerer, M., Ungerer, G., & Herholdt, J. (2016). Navigating strategic possibilities: Strategy formulation and execution practices to flourish. Randburg, South Africa: KR Publishing. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Using Data to Guide Business Decisions 10 Carolyn Giordano, PhD, FASAHP LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ Understand the essentials of collecting and analyzing data, Identify the pros and cons of quantitative and qualitative data, Identify security and ethical considerations of collecting and using data, Implement action plans based on the collection and analysis of data, and Apply data collection and analysis principles to the Accreditation Council for Occupational Therapy Education® (ACOTE; 2018) standards related to the analysis and planned action of collection of data. KEY TERMS AND CONCEPTS • • • • Dashboard report Data Data visualization Descriptive statistics • • • • Figures Graphs Mixed methods Qualitative methods “It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.” —Sir Arthur Conan Doyle, A Scandal in Bohemia (1891, para. 24) OVERVIEW M aking thoughtful decisions based on a thorough analysis of existing literature and data can be challenging, and the success of occupational therapy managers and administrators relies on navigating many sources of data to make sound business decisions. Just as occupational therapy practitioners use evidence to drive treatment plans, data-driven managers and administrators keep data at the forefront of any process. Because data are of no use unless someone takes action on them, data should be collected purposefully and be actionable. Data should drive budgeting, long- and short-term planning, process implementation, staff retention and development, • Quantitative methods • Outliers • Tables and more. Increasingly, technology allows for tracking every interaction, leaving users with huge quantities of data. It is not enough to simply have large amounts of data. Having a solid plan, asking the right research questions, and knowing how to analyze and use the data are critical to running a practice. This chapter guides occupational therapy managers and administrators in using data in practical ways, including asking the right questions, identifying sources of data, understanding whether data can be trusted, and communicating findings. ESSENTIAL CONSIDERATIONS The research process has 8 steps: 1. Identify the problem or research question. 2. Scan the literature. 3. Make a plan, including timeline, budget, and communication of results. Be very detailed in this stage, and make sure that the plan is realistic and ties back into the research question. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.010 99 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Using Data to Guide Business Decisions 10 Carolyn Giordano, PhD, FASAHP LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ Understand the essentials of collecting and analyzing data, Identify the pros and cons of quantitative and qualitative data, Identify security and ethical considerations of collecting and using data, Implement action plans based on the collection and analysis of data, and Apply data collection and analysis principles to the Accreditation Council for Occupational Therapy Education® (ACOTE; 2018) standards related to the analysis and planned action of collection of data. KEY TERMS AND CONCEPTS • • • • Dashboard report Data Data visualization Descriptive statistics • • • • Figures Graphs Mixed methods Qualitative methods “It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.” —Sir Arthur Conan Doyle, A Scandal in Bohemia (1891, para. 24) OVERVIEW M aking thoughtful decisions based on a thorough analysis of existing literature and data can be challenging, and the success of occupational therapy managers and administrators relies on navigating many sources of data to make sound business decisions. Just as occupational therapy practitioners use evidence to drive treatment plans, data-driven managers and administrators keep data at the forefront of any process. Because data are of no use unless someone takes action on them, data should be collected purposefully and be actionable. Data should drive budgeting, long- and short-term planning, process implementation, staff retention and development, • Quantitative methods • Outliers • Tables and more. Increasingly, technology allows for tracking every interaction, leaving users with huge quantities of data. It is not enough to simply have large amounts of data. Having a solid plan, asking the right research questions, and knowing how to analyze and use the data are critical to running a practice. This chapter guides occupational therapy managers and administrators in using data in practical ways, including asking the right questions, identifying sources of data, understanding whether data can be trusted, and communicating findings. ESSENTIAL CONSIDERATIONS The research process has 8 steps: 1. Identify the problem or research question. 2. Scan the literature. 3. Make a plan, including timeline, budget, and communication of results. Be very detailed in this stage, and make sure that the plan is realistic and ties back into the research question. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.010 99 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 100 SECTION II. Organizational Planning and Culture 4. Collect data. Gather data from existing or new data sources, and be prepared for surprises. A plan to run a focus group with 10 individuals might end up with only 5 showing up. 5. Prepare data. Examine data for errors, duplicate records, and outliers. 6. Analyze data. Compute frequencies and descriptive statistics first, then determine the appropriate inferential analysis. Create themes from qualitative data and begin synthesizing with the quantitative data. Compare trends and determine whether any predictions can be made. 7. Report findings. The data analysis should be the basis from which a decision is made. Is the research question answered? How confident are you in the results? 8. Assess the process. Are more data points needed after reviewing the data and implementing the plan? Debrief with a team. What could be done differently next time? What was a surprise? Did questions come up? Step 1. Identify the Problem or Research Question Proper planning is critical to any research process. Time is wasted if data are collected that do not answer the research question. Start by writing down the problem statement or research question to help frame project and limit the resources and scope. Before making any decisions, identify your needs. Begin by documenting questions and goals, and decide whether the resources are available to collect and analyze the data. Asking relevant, answerable questions is the key to good planning and is the first step toward being able to know what data are needed. Step 2. Scan the Literature The next step is to research the academic and business environment to see what has been published about the research question or topic. Learn from others’ successes and failures, and document what can be translated into the project. Reading key pieces of literature and studying studies and reports can guide planning. For example, if the goal is to increase client satisfaction in client-centered approaches, read the literature to see what questionnaires have been used to assess this topic, in which type of setting, and on what type of population. Reviewing the literature may provide existing points of data, personal contacts in the field, and ideas with which to move forward. This review will drive the project and protect its budget, it will reduce replicating what is already known and can uncover the pitfalls of others. This step will help determine the right questions to ask. Understanding the environment will help managers and administrators identify needs and measure resources. Step 3. Make a Plan A focused research plan will help guide the study and limit resources. The plan should be based not only on anecdotes or observations but also on a thorough review of the literature. As stated in Step 2, reviewing what data have been collected at other institutions or centers will help guide the research study. Project planning should always start with a research question and include steps for analyzing and communicating the research. Many who do planning and assessment rely on the SMART goal process (Doran, 1981). SMART stands for Specific, Measurable, Attainable, Realistic, and Tangible (or Time-Bound). The SMART model sets planners up for success, because a specific goal keeps the outcomes focused and limits wasted time and financial resources. A measurable goal drives the planning process by ensuring information is based on available data. It separates the dreams (e.g., “Wouldn’t it be nice to know this if we had all the access, money, and time in the world?”) from the realities of (e.g., “We can gauge this with our available resources”). Similarly, attainable goals ground researchers in reality and limit wasting time and effort. The program goal may be to use gold and diamond bricks as building materials in a new office space, but that is not attainable. This also leads to a realistic goal. “Shooting for the moon” will waste a lot of time if managers or administrators do not recognize their limits. Finally, goals should be tangible or time bound. Include time parameters in setting a goal. When should data collected by? When should data be reviewed? When do decisions need to be made and results shared? Exhibit 10.1 shows a template for a research plan. Step 4. Collect Data Without a clear focus when assessing goals, managers and administrators can be overwhelmed with data and unable to make decisions. Collecting, organizing, analyzing, and presenting data are essential skills required for any decision making. Professionals now can gather data in many more ways than ever before and do not have to rely solely on indirect observations, such as interviews, focus groups, surveys, or questionnaires. Direct encounters can be measured, analyzed, and turned into action plans. Technology is used in the workplace to find and recruit employees, to monitor and improve performance, to measure client interactions, and to track budget and marketing. Data sources Data are pieces of information used as a source of thoughtful discourse, planning, and decision making and can include direct observations of opinions, attitudes, and perceptions that are given in both quantitative and qualitative forms. These data sources can be gathered in the forms of a customer, client, or patient satisfaction survey; focus groups; or interviews. These data provide a great deal of information but can be prone to bias and external factors. Quantitative methods of data collection provide numerical responses to closed-ended questions (Babbie, 2010) and include objective measurements of data points and their Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 10. Using Data to Guide Business Decisions 101 EXHIBIT 10.1. Research Plan What is your research question? What is your sample? How are you going to collect your data? Are you going to analyze the data or will you hire someone? What is your timeline? What is your budget? Who is your audience, and how will you communicate your findings to them? analysis with mathematics or statistics. They provide finite insight on the measurement of relationships. Questions can be asked in a binary (e.g., yes/no, like/dislike) or on a Likert scale (e.g., “Please rate your level of satisfaction from 1 = very satisfied to 5 = very dissatisfied” or “Please rate your level of pain on a scale from 1 to 10”). Quantitative analysis can be effective, quick, and relatively inexpensive to administer to large samples. Qualitative methods of data collection include openended questions on surveys, questions in focus groups, or interviews, and gather data by generalizing information from individuals or groups of people to explain an event. Often, individuals are asked to comment on how they feel or describe why they think a certain way. Interviews and focus groups can adopt structured or unstructured methods and can lead to a rich variety of data. Qualitative methods can surface issues previously unknown or provide deeper perspectives on populations. However, they can be time intensive and costly to run, analyze, and interpret. Combining quantitative and qualitative research results in mixed methods data collection. This approach is best when incorporated in the research planning phase to help meet a timeline and budget, but it also can be done after 1 stage of the research has been analyzed. Quantitative analysis often provides a data point that can help guide decision making. For example, knowing that 90% of clients are satisfied with a certain occupational therapy practitioner in the office is very helpful. However, adding a qualitative question can help explain why and provide support to what the team is doing or to inform making adjustments and improvements in other areas. In addition to data collection in a planned research study, data also are collected on everyday devices that are not always intended for research purposes. Smartphones, wearable devices, and smart home and office technology are making automatic quantitative data collection more commonplace. Office tracking data connected with electronic health records can unveil issues and increase productivity. Such data connectivity can help improve care while controlling costs. More precisely, tailored health plans can be created by using the health data from smart devices that clients wear. By extracting enough direct data, predictive analytical models can help guide decisions on care and services offered. Additionally, with sound data analysis, big data can help management answer questions that were impossible several years ago (George et al., 2016). Using different sources of data can help gain better understanding of a particular issue. If 1 data point is a specific client outcome, another data point can help explain why or how clients felt about the process. For example, although understanding that clients have a better range of motion after 6 weeks of therapy is important, coupling the data with satisfaction and attitudes about the therapy process is just as important. This process would help managers or administrators understand the likelihood that clients would recommend the therapy to someone else, which might increase business. Similarly, advertising campaigns have data in “click-through” numbers and can often tally the number of advertising views. However, without another source of data investigating opinions and perceptions, it may not be clear whether those advertisements resulted specifically in increased number of clients and how prospective clients perceived those advertisements. Essentially, knowing that the clients saw an advertisement is not enough; follow up is required to learn if they liked the advertisement and if it, in turn, led them to the business. Storing data Once data have been collected, planning how to safely store that data is important. The storage system should be accessible by password, with only the appropriate individuals Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 102 SECTION II. Organizational Planning and Culture having access to the data. When possible, data should be kept anonymous, or at least confidential. A good reference guide on data safety and security standards can be found in the Patient-Centered Outcomes Research Institute’s (PCORI; 2018) Methodology Standards. Step 5. Prepare Data Before data can be analyzed, they need to be prepared. Data preparation entails examining the collected data for errors, bias, missing data, and outliers. Errors Research can be prone to errors. Even research that has gone through extensive planning can be subject to flaws along the way. Sources of errors can stem from sampling the wrong population. If researchers sample only a small number of individuals, they may not be able to generalize their findings to a larger population. Similarly, if researchers sample a population that does not represent the group they are interested in, their results may not be accurate. Sampling can also be biased. It is easy to ask friends, neighbors, family, or colleagues how they feel about a certain issue, but that type of convenience sample may not provide trusted results. At the core of good research is objective, randomly assigned participants who provide data. Errors can also be made in collecting and storing data. Although many researchers no longer rely on paper data collection, that modality still exists. Translating data from paper to computer systems can lead to data-entry errors. Quality control processes should be in place to ensure data are entered correctly. Electronic systems contain less error in data entry, but data should still be reviewed. When analyzing data in a spreadsheet, take time to assess whether the data look correct. Missing data and outliers PCORI (2018) suggests that you plan for monitoring the research process to avoid missing data. This means not waiting until the end of the collection period to review data but checking in on the research process at regular intervals. Next, create a plan for how to handle missing data. Several tasks should be done before beginning a data analysis. First, scan the data by running simple descriptive statistics on each variable. Descriptive statistics describe the data through a frequency distribution or measures of central tendency or variability, such as mean scores, ranges, and standard deviations (Creswell, 2014). Descriptive statistics do not infer anything about a larger population but simply describe the data. By running a frequency distribution, it is possible to see whether any data are missing and whether the missing data are clustered in a particular area. The data distribution and range of scores can help determine whether there are any extreme cases that should not be included. These extreme cases are called outliers (Salkind, 2010) and can affect the mean significantly. Review outliers by running a frequency distribution on the data set to review each case. This process will help identify missing cases or extreme deviations in scores. An example of an outlier would be if the research on the geriatric community contains an age of 38 in the descriptive analysis, which indicates a problem with the data. Or, if 1 person scored 100 on a test but the rest of the group maxed out at 60, think about what to do with that outlier score of 100. One outlier, even if it is accurate, can affect the mean scores and alter decisions. Options for handling missing data and outliers include keeping the data as they are, deleting the entire entry, or entering a mean or aggregate data point. A similar process can be done with outliers. Once a choice is made, document the decision and report it when the results are communicated. Step 6. Analyze Data After reviewing the data and finding all records to be accurate, analyze the data. Microsoft Excel (Redmond, WA) has statistical functionality, but other programs such as IBM SPSS (Armonk, NY), SAS (Cary, NC), and R (Vienna, Austria) provide a more enhanced level of analysis. Begin with simple descriptive statistics, such as the count, percentage, and range of the data by certain groupings. Presenting measures of central tendency (e.g., mean, median, mode) will help in understanding the data as a whole and by different groupings. For example, a manager or administrator might answer the question of what is the mean satisfaction score by male or female clients, and did it differ between them? Return to the research question, and identify the correct statistic to answer it. These statistics depend on the sample size and research methodology, but an example would be asking whether to predict something via regression equations or see if there are mean differences between groups and knowing if the sample is large enough and of the right type of data to answer these questions. Step 7. Report Findings Sharing data with others is key to convincing stakeholders of a manager’s or administrator’s plans as a decision maker; however, be wary of modern infographics and pie charts. The goal is to present findings in a clear manner and create an action plan. A communication plan should be created from the beginning of the research process. Decide to whom to communicate—internal and external stakeholders—and communicate with them. According to Knaflic (2015), “being able to visualize data and tell stories with it is key to turning it into information that can be used to drive better decision making” (p. 2). Knaflic suggested 6 guidelines for data communication: 1. 2. 3. 4. 5. 6. Understand context. Choose an appropriate display. Eliminate clutter. Focus attention where you want it. Think like a designer. Tell a story. (p. 12) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 10. Using Data to Guide Business Decisions Although it is beyond the scope of this chapter to detail data visualization strategies, which include methods of sharing information in charts, tables, or figures, occupational therapy managers and administrators should remember that anyone can use a Microsoft Office tool to create a chart or graph. However, making that information meaningful depends on deliberately presenting relevant data that the audience needs to know. A common reporting tool is a dashboard report, which is a summary that contains data points to measure performance success in various areas (Figure 10.1). This report is meant to be a quick reference tool. Although many commercial interactive dashboard tools are available, visualization can be as simple as up-and-down arrows, or red–yellow–green circles, next to a variable of interest. A dashboard provides a quick guide and is based on data elements. A sample of outcomes in a typical occupational therapy practice might include client performance, cost of service, success of treatment, quality-of-life indicators, and or client satisfaction (Pitonyak, 2014). When presenting data, remember to return to the research question and answer it as simply as possible. In addition to the narrative text, answer it with a table, a figure, or a graph. Tables are rows and columns of data and show exact data points. Graphs are a type of figure that illustrates quantitative data points and are best when data are too complex to be reported as a table and the decision maker or audience would not be able to swiftly understand the data presented in the table. A simple graph can easily show outliers in data and can educate about the differences in groups. Figures are images, maps, or diagrams and should be used to present complicated results. Each reporting method should be concise but include explanations and legends where appropriate, be clearly labeled, and be legible. Every day more and more data visualization tools and techniques are available for purchase. Common ones are ­Microsoft BI (Redmond, WA), Tableau (Seattle, WA), and ­Infogram (San Francisco, CA). These are usually easy to manipulate but require a good understanding of data management to be able to load in the raw data tables for the visualizations to work. Without the underlying data being free from 103 error, these tools are worthless. There is also a tendency for these tools to be more distracting than informative, and in the end, simpler may be better when reporting results. Step 8. Assess the Process After analyzing and presenting the data, review the process. Were the timeline and budget met? Was the research question answered? What feedback was received from stakeholders who were presented with the data? Many times the research process not only leads to data that can help managers or administrators make decisions but also uncovers new questions and ideas, leading perhaps to a new project! Review Questions 1. What is the first step in the research process, and why is this step important? Who would you consult in this first step? 2. What does the M in SMART goals stand for, and why is it important? 3. What is a dashboard report, and what types of data can you display on it? What are some limitations of dashboard reports? PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Consider Outcomes What is the desired outcome in collecting and analyzing data? Is it client satisfaction? Client outcome improvement? Staffing issues? Whatever the problem to be solved, it should be practical and also reflect client or organizational needs. Identifying outcome, client satisfaction, and practitioner productivity can be done in several ways depending on the organization. Managers or administrators may choose to identify the outcome alone or to work with a team. If choosing to work alone, know that there will be bias and a limited perspective. If working with a team, keep the team small, and appoint a leader or chair to make any final decisions and to move the project forward. This team should also be FIGURE 10.1. Dashboard example. Goal Performance Third quarter revenue up 10% after marketing plan implemented in Quarter 1. Revenue up 12% in the third quarter. Increase staffing by filling open positions by September 1. Staffing level 100%, onboarding training underway. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 104 SECTION II. Organizational Planning and Culture EXHIBIT 10.2. Questions to Ask a Data Scientist ■ How did you obtain the data? ■ Are there other methods you could use to obtain the data? ■ What was your sampling plan? Does the respondent characteristics match the larger population? ■ What is the sample size? ■ Describe the data for me. Where there any outliers, and how did they affect results? ■ How did you analyze the data? Why? Are there other methods you could have used? tasked with reviewing results and ensuring all stakeholders are communicated with properly. Working With a Data Scientist If the idea of working with spreadsheets and doing statistical analysis on data is not in the skill set of a manager or administrator, it is possible to outsource some of this work to someone who is knowledgeable about data and statistics. If the organization chooses to hire a data scientist, understanding the scope of work is key. Does the organization need someone to run the entire project, or just to pull data and run the numbers. See Exhibit 10.2 for a list of questions to ask a data scientist. A Practical Example An occupational therapy department has been in operation for more than 5 years and serves a variety of clients. The department has collected data on the clients served, and the supervisor is asking for longitudinal productivity numbers. How would data be used data to support this request? Case Example 10.1 provides a case example of a new school district manager of occupational therapy using and analyzing data. Ethics An additional consideration is the ethical dilemma of using data for marketing and research purposes without employee or client consent. If using technology to track encounters and monitor other information, use flyers or signage to inform individuals, such as clients and employees. Store that information safely and securely, and review cyber technology standards. This would include, but go beyond, reviewing and implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA; P. L. 104–191) privacy and security rules regularly (U.S. Department of Health and Human Services [HHS], 2013). HHS (2018) also has a website (https://bit.ly/2uJAcjr) that lists HIPAA-covered entities that are subject to following cybersecurity rules. Review Questions 1. How do you think clients may react when they learn that you may be using technology to track encounters and interactions? 2. Where can you find information about emerging cyber technology standards? 3. As documented in the AOTA (2015) Occupational Therapy Code of Ethics (2015), the standard for Nonmaleficence states that “Occupational therapy personnel shall refrain from actions that cause harm” (p. 3). Describe what harm may come from collecting data from clients using technology without their consent. CASE EXAMPLE 10.1. Janelle: A School District Manager Needs to Review Janelle, a new school district manager of occupational therapy services in Pennsylvania, was asked to review child services and outcomes from the last 3 years in 2 high schools so she can properly allocate resources. She requested data from the school district. The data file came in a Microsoft Excel format and contained variable names for each column, and 1 row of data for each student encounter. She opened the data file and ran descriptive statistics on each variable of interest. In the frequency distribution, she saw several cases (i.e., missing rows) of missing data and 3 outliers, or extreme scores in her data. Janelle discussed with her team the possible causes for this and decided to keep missing data but to remove the 3 outliers from the data set. She then looked for differences between the 2 high schools on services provided and outcomes over the past 3 years. She compared demographic information, such as gender, age, race, or ethnicity. She also compared student socioeconomic status by comparing students who are receiving free-lunch vouchers. She presented her findings in a table and included a few graphs that illustrated the mean differences in her demographic breakdowns and showed trends by year. Janelle’s research and data allowed her to make the case that more resources are needed. She reported her findings to the school district and at a monthly school board meeting to the public, in which it was decided that more advanced statistics are needed to build a predictive model. She partnered with a data analyst to see which variables are likely to predict successful outcomes. Review Questions 1. 2. 3. Review Janelle’s approach to keeping the instances of missing data. She decided not to replace the missing data with mean scores or to delete the entire row of data, removing all information for that particular case or student, but instead left the missing data as is and continued with her analysis. Do you agree with this approach? Why or why not? Janelle reported her findings in both tabular and graphical form. Why is presenting this way important? Imagine you were a member of the audience during this school board meeting. What questions might you have for Janelle and her team as they move forward with building a predictive model? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 10. Using Data to Guide Business Decisions 105 SUMMARY REFERENCES When starting a new program, business, or practice, occupational therapy managers and administrators must understand the data that drive all aspects of decision making. Knowing how to implement action plans based on data collection and analysis is key. Action plans may be client based, dealing with safety and the success and timeliness of services, or internal business based, such as employee performance or finances. Either type requires a clear vision, organized SMART goals, sound data collection that is free from bias, and strong interpretation of the data. ❖ Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE®) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2). https://doi.org/10.5014/[TK] American Occupational Therapy Association. (2015). Occupational therapy code of ethics (2015). American Journal of Occupational Therapy, 69, 6913410030. https://doi.org/10.5014 /ajot.2015.696S03 Babbie, E. R. (2010). The practice of social research (12th ed.). Belmont, CA: Wadsworth Cengage. Creswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches (4th ed.). Thousand Oaks, CA: Sage. Doran, G. T. (1981, November). There’s a SMART way to write management’s goals and objectives. Management Review, 70, 35–36. Doyle, A. C. (1891). A scandal in Bohemia. Retrieved from https:// www.gutenberg.org/files/1661/1661-h/1661-h.htm George, G., Osinga, E., Lavie, D., & Scott, B. (2016). From the editors: Big data and data science methods for management research. Academy of Management Journal, 59, 1493–1507. https://doi .org/10.5465/amj.2016.4005 Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104–191. Knaflic, C. N. (2015). Storytelling with data: A data visualization guide for business professionals. Hoboken, NJ: Wiley. Patient-Centered Outcomes Research Institute. (2018). PCORI methodology standards. Retrieved from https://www.pcori.org /sites/default/files/PCORI-Methodology-Standards.pdf Pitonyak, J. S. (2014). Occupational therapy evaluation and evidence-based practice. In J. Hinojosa & P. Kramer (Eds.), Evaluation in occupational therapy: Obtaining and interpreting data (4th ed., pp. 267–280). Bethesda, MD: AOTA Press. Salkind, N. (2010). Encyclopedia of research design. Thousand Oaks, CA: Sage. U.S. Department of Health and Human Services. (2013). Summary of the HIPAA security rule. Retrieved from https://www.hhs.gov /hipaa/for-professionals/security/laws-regulations/index.html U.S. Department of Health and Human Services. (2018). Cyber security guidance material. Retrieved from https://www.hhs.gov /hipaa/for-professionals/security/guidance/cybersecurity/index .html LEARNING ACTIVITIES 1. Use Exhibit 10.1 to create a hypothetical research plan. 2. You have received a data set containing more than 1,000 records of client satisfaction ratings for the 5 occupational therapy practitioners on your staff. Your first step is to run descriptive statistics to determine whether any data are missing or outliers exist. You find 15 records with missing data for satisfaction scores, which is your main research objective. You also review and notice there are 4 scores outside your expected range. Describe your plan for handling missing data and your rationale. Next, describe your plan for handling your outliers and why you chose that method. ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ ■ ■ ■ ■ ■ B.1.4. Qualitative Statistics and Qualitative Analysis B.4.6. Reporting Data B.4.7. Interpret Standardized Test Scores B.4.8. Interpret Evaluation Data B.6.2. Qualitative and Quantitative Methods B.6.3. Scholarly Reports. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Risk Management and Contingency Planning CHAPTER Sarah Corcoran, OTD, OTR/L 11 LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ ■ Define risk, risk management, and contingency planning; Identify examples of types of risk within an organization; Analyze the contextual factors that have shaped the history of risk management in health care; Describe the 5 risk management strategies; Discuss the relationship between risk management and quality improvement within an organization; and Recognize responsibilities of occupational therapy practitioners in risk management and contingency planning. KEY TERMS AND CONCEPTS • • • • • Adverse event Clinical risk Contingency plan Incident report Near miss • • • • • Plan–Do–Study–Act Cycle Quality improvement Risk Risk management Risk management plan OVERVIEW R isk is everywhere. Because people need and want to do things, they find ways to manage risk. Think about the risks that people notice, avoid, or create every day. People set alarm clocks to avoid oversleeping. Students study for exams to avoid the risk of failing a course. Homeowners install gutters so that water does not damage their home. Occupational therapy practitioners recommend grab bars and adaptive equipment to prevent the risk of a client falling. How would each day be different if risks were not managed? A world without risk is appealing but not possible. Therefore, people assess risks and analyze strategies to effectively respond to potential hazards. A business, regardless of its size and structure, must identify and manage risks in order to succeed. Risk is defined as a possible, uncertain event usually measured by how likely it is to occur and the severity of the potential impact (Centers for Disease Control and Prevention [CDC], 2006; Ross, 2012). Risk management is the practice of identifying, analyzing, • • • • Risk matrix Risk report Root cause analysis Sentinel events controlling, reporting, and monitoring the likelihood and potential impact of events that threaten an organization’s resources (CDC, 2006; Clarke, 2000; Dickson, 1995). The greatest resources of an organization include its mission or purpose, its employees, and its consumers. This chapter covers information that occupational therapy leaders need to know about risk management in the context of organizational planning and culture. ESSENTIAL CONSIDERATIONS Risk Management in Health Care Like any business, health care organizations face exposures to many risks. In addition to clinical risk, or risk associated with patient safety and the delivery of care, it is also essential for the organization to consider operational, strategic, financial, workforce, legal, technology, and hazard risks (American Society for Healthcare Risk Management [ASHRM], 2016). These types of risk and examples are shown in Exhibit 11.1. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.011 107 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Risk Management and Contingency Planning CHAPTER Sarah Corcoran, OTD, OTR/L 11 LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ ■ Define risk, risk management, and contingency planning; Identify examples of types of risk within an organization; Analyze the contextual factors that have shaped the history of risk management in health care; Describe the 5 risk management strategies; Discuss the relationship between risk management and quality improvement within an organization; and Recognize responsibilities of occupational therapy practitioners in risk management and contingency planning. KEY TERMS AND CONCEPTS • • • • • Adverse event Clinical risk Contingency plan Incident report Near miss • • • • • Plan–Do–Study–Act Cycle Quality improvement Risk Risk management Risk management plan OVERVIEW R isk is everywhere. Because people need and want to do things, they find ways to manage risk. Think about the risks that people notice, avoid, or create every day. People set alarm clocks to avoid oversleeping. Students study for exams to avoid the risk of failing a course. Homeowners install gutters so that water does not damage their home. Occupational therapy practitioners recommend grab bars and adaptive equipment to prevent the risk of a client falling. How would each day be different if risks were not managed? A world without risk is appealing but not possible. Therefore, people assess risks and analyze strategies to effectively respond to potential hazards. A business, regardless of its size and structure, must identify and manage risks in order to succeed. Risk is defined as a possible, uncertain event usually measured by how likely it is to occur and the severity of the potential impact (Centers for Disease Control and Prevention [CDC], 2006; Ross, 2012). Risk management is the practice of identifying, analyzing, • • • • Risk matrix Risk report Root cause analysis Sentinel events controlling, reporting, and monitoring the likelihood and potential impact of events that threaten an organization’s resources (CDC, 2006; Clarke, 2000; Dickson, 1995). The greatest resources of an organization include its mission or purpose, its employees, and its consumers. This chapter covers information that occupational therapy leaders need to know about risk management in the context of organizational planning and culture. ESSENTIAL CONSIDERATIONS Risk Management in Health Care Like any business, health care organizations face exposures to many risks. In addition to clinical risk, or risk associated with patient safety and the delivery of care, it is also essential for the organization to consider operational, strategic, financial, workforce, legal, technology, and hazard risks (American Society for Healthcare Risk Management [ASHRM], 2016). These types of risk and examples are shown in Exhibit 11.1. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.011 107 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 108 SECTION II. Organizational Planning and Culture EXHIBIT 11.1. Description of Enterprise Risk Domains ERM Risk Domains Domain Operational Clinical/Patient Safety Description/Example The business of health care is the delivery of care that is safe, timely, effective, efficient, and patient-centered within diverse populations. Operational risks relate to those risks resulting from inadequate or failed internal processes, people, or systems that affect business operations. Included are risks related to: adverse event management, credentialing and staffing, documentation, chain of command, and deviation from practice. Risks associated with the delivery of care to residents, patients and other health care customers. Clinical risks include: failure to follow evidence based practice, medication errors, hospital acquired conditions (HAC), serious safety events (SSE), and others. Strategic Risks associated with the focus and direction of the organization. Because the rapid pace of change can create unpredictability, risks included within the strategic domain are associated with brand, reputation, competition, failure to adapt to changing times, health reform or customer priorities. Managed care relationships/partnerships, conflict of interest, marketing and sales, media relations, mergers, acquisitions, divestitures, joint ventures, affiliations and other business arrangements, contract administration, and advertising are other areas generally considered as potential strategic risks. Financial Decisions that affect the financial sustainability of the organization, access to capital or external financial ratings through business relationships or the timing and recognition of revenue and expenses make up this domain. Risks might include: costs associated with malpractice, litigation, and insurance, capital structure, credit and interest rate fluctuations, foreign exchange, growth in programs and facilities, capital equipment, corporate compliance (fraud and abuse), accounts receivable, days of cash on hand, capitation contracts, billing and collection. Human Capital This domain refers to the organization’s workforce. This is an important issue in today’s tight labor and economic markets. Included are risks associated with employee selection, retention, turnover, staffing, absenteeism, on-the-job work-related injuries (workers’ compensation), work schedules and fatigue, productivity and compensation. Human capital associated risks may cover recruitment, retention, and termination of members of the medical and allied health staff. Legal/Regulatory Risk within this domain incorporates the failure to identify, manage and monitor legal, regulatory, and statutory mandates on a local, state and federal level. Such risks are generally associated with fraud and abuse, licensure, accreditation, product liability, management liability, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs) and Conditions for Coverage (CfC), as well as issues related to intellectual property. Technology This domain covers machines, hardware, equipment, devices and tools, but can also include techniques, systems and methods of organization. Healthcare has seen an explosion in the use of technology for clinical diagnosis and treatment, training and education, information storage and retrieval, and asset preservation. Examples also include Risk Management Information Systems (RMIS), Electronic Health Records (EHR) and Meaningful Use, social networking and cyber liability. Hazard This ERM domain covers assets and their value. Traditionally, insurable hazard risk has related to natural exposure and business interruption. Specific risks can also include risk related to: facility management, plant age, parking (lighting, location, and security), valuables, construction/renovation, earthquakes, windstorms, tornadoes, floods, fires. Note. ERM = enterprise risk management. Copyright © 2016 by the American Society for Healthcare Risk Management. Reprinted with permission. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 11. Risk Management and Contingency Planning Historical Perspective Risk management in health care has evolved as health care has changed in the United States (see Figure 11.1). Hospitals began to focus on risk management as malpractice claims increased in the 1970s (ECRI Institute, 2014). The aim of risk management in the 1970s was to defend organizations from legal and financial types of risks. Over the next couple of decades, the health care industry began to connect clinical risk management with quality improvement, which is the continual process of monitoring outcomes to ensure optimal care delivery within an organization (American Society for Healthcare Risk Management of the American Hospital Association, 2007). National quality improvement and risk management organizations formed, and regulatory agencies set standards for health care organizations’ risk management programs. For example, in 1996, the Joint Commission began to require organizations to investigate and report sentinel events, or adverse events resulting in death or serious harm to a patient (The Joint Commission, 2017b). An adverse event is an incident that causes an undesired outcome, such as harm to a patient, not expected during the normal delivery of care (Levinson, 2012). In 1999, the Institute of Medicine released a report enti­t led To Err is Human: Building a Safer Health System, which revealed a high rate of death from medical errors in the United States. This report prompted the health care industry to consider the larger, systemic causes of adverse events and near misses. A near miss is an unplanned event, or close call, that could have caused harm to a person but did not because of chance or intervention (National Safety Council, 2013; U.S. Department of Veterans Affairs, 2015). The Joint Commission and Centers for Medicare and Medicaid Services (CMS) began requiring health care organizations to report adverse events and near misses and provided tools to guide patient safety programs. Even with a heightened focus on managing clinical risk from a system perspective, the National Patient Safety Foundation’s 2015 report Free From Harm included the agency’s assessment that medical errors and related consequences were still rampant. A paper published in 2016 by physicians Makary and Daniel at Johns Hopkins University suggested that medical error is the 3rd leading cause of death in the United States. The occupational therapy profession has also recognized the presence of clinical risk in occupational therapy practice. In 2006, Mu et al. published results from a national survey of occupational therapy practitioners that indicated that practice errors were frequent, even among the most experienced clinicians. The occupational therapy practitioners in this study also reported improvement in their own practice and client outcomes when the practitioners reported errors. A follow-up study identified strategies for occupational therapy practitioners, students, and managers to reduce practice errors and build a culture of safety within organizations (Mu et al., 2011). The occurrence of practice errors may also be evident in review of malpractice claims. Between 2006 and 2015, the professional liability companies CNA and Healthcare Providers Service Organization reported that malpractice claims for occupational therapy practitioners insured through these companies totaled $2,717,629 (CNA, 2017). Health care leaders, including occupational therapy prac­ titioners and managers, must meet the complex task of managing all areas of risk that are present within their work settings. With the expansion of technology, health care systems rely on electronic systems to secure large amounts of private information. Regulatory agencies (e.g., CMS) expect health care organizations to take responsibility for the electronic systems that they use. As companies merge to develop expansive health care systems, leaders must stay aware of the strategic and financial risk exposures. Organizations need to adhere to specific regulations and know the legal risks in their ventures. Risk management in health care is complex, and those responsible for risk management must understand all types of risk and use essential risk management strategies. FIGURE 11.1. Health care risk management events in the United States, 1980–2015. 1980 • American Society for Healthcare Risk Management established (1980) • Agency for Health Care Policy and Research created (1989) 1990 • National Committee for Quality Assurance formed (1990) • The Joint Commission issued Sentinel Event Policy (1996) • Institute of Medicine released To Err is Human: Building a Safer Health System (1999) 109 2000 • The Joint Commission announced National Patient Safety Goals (2002) • National Quality Forum issued list of Serious Reportable Events (2002) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 2010 • World Health Organization developed Multiprofessional Patient Safety Curriculum (2011) • National Patient Safety Foundation (2015) released Free From Harm 110 SECTION II. Organizational Planning and Culture Risk Management Team Depending on an organization’s size and structure, the organization may appoint a person or a team of people to conduct risk management, or it may outsource to a risk management company (ASHRM, 2006b, 2006c; American Society for Healthcare Risk Management of the American Hospital Association, 2007). The resources and needs of each organization will determine who is responsible for risk management activities. People who hold risk management positions can have different professional backgrounds, but the focus of risk management is the same. Key risk management responsibilities include identifying the organization’s critical risks, learning industry standards and regulations, creating policies to increase safety, educating staff about potential risks and plans, investigating complaints, working with legal matters (e.g., malpractice, workers’ compensation), tracking data to locate root causes and action plans, and reporting risk-related information to stakeholders. Risk Management Strategies There are 5 key risk management steps, or strategies: 1. 2. 3. 4. 5. Plan, Assessment, Analysis, Response, and Report and monitoring. Guiding questions for each step are suggested in Table 11.1. Risk management plan Creating a risk management plan is the first step to developing a risk management program. This plan defines the business’s philosophy on risk. For example, a business’s risk plan may specify that patient safety is the responsibility of all employees. It may state that the members of the organization must create and uphold a just culture in which the focus is on learning, communicating, and improving quality of care. The organization identifies key terms and definitions that are important to how it understands risk and conducts risk management activities. The plan also names the person(s) responsible for risk management within the structure of the organization (CNA, 2014; ECRI Institute, 2014). The processes for day-to-day risk management, such as how patient complaints are handled or how policies are revised, are outlined here. Timelines to guide risk management are plotted, including how often risk priorities are assessed. For example, a business may indicate that the plan itself will be evaluated and modified as needed but at least annually. Overall, this plan conveys the need to know information about risk management within the organization to all employees and external stakeholders, including consumers, accrediting bodies, and potential business partners. For this reason, the plan should be readily available and shared with employees upon orientation and on a routine basis, especially when revisions are made. Risk assessment Next, the organization must determine the risks to which it is exposed. The aim of risk assessment is to find areas of vulnerability within the organization, potential threats, and the impact if the risk occurs (Ross, 2012). Health care leaders can identify the most likely and serious risk exposures by learning current industry trends. They want to know what risks have threatened other similar businesses so that they can proactively manage these risks and avoid negative outcomes for their own organization. They also study current laws, regulations, and professional standards that point to critical industry risks related to the provision of care. For example, The Joint Commission sets Table 11.1. Risk Management Strategies and Guiding Questions RISK MANAGEMENT STRATEGY GUIDING QUESTIONS Plan ■ ■ ■ ■ ■ What is the organization’s philosophy on risk? Who is responsible for risk management? What are the risk program’s goals? How will the organization conduct daily risk management activities? How often will the organization formally review the risk plan and related policies? Assessment ■ ■ ■ ■ Which risks are most likely to impact this organization? What unexpected events have occurred within this organization? What trends are observed through incident reports? What trends are observed through employee and patient satisfaction surveys? Analysis ■ What is the impact if the risk occurs? ■ What caused an unexpected event? ■ What are possible ways to deal with the risk? Response ■ How will the organization act on the risk? Will it mitigate, eliminate, accept, or transfer the risk? Reporting and monitoring ■ How will the organization monitor ongoing and new risks? ■ What information is important to communicate to internal and external stakeholders? ■ How will this communication occur? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 11. Risk Management and Contingency Planning 111 FIGURE 11.2. Sample risk matrix. Risk Ranking Matrix Risk Map Critical 5 Impact Moderate 4 3 Insignificant 2 1 Unlikely Potential Likely Likelihood 1 2 3 4 5 Source. Copyright © 2014 by American Society for Healthcare Risk Management. Reprinted with permission. minimum requirements that hospitals and home health organizations must meet to assess risks such as infection, oxygen and medication management, and patient falls. During risk assessment, organizations prioritize risks to most effectively use their resources, including time, money, and staff training. A risk matrix is a mapping tool used to rate the likelihood and severity of the impact of risks in order to identify the most critical risks to be addressed (see Figure 11.2; ASHRM, 2006a; CMS, 2007). Organizations’ risk managers or risk management teams create a matrix to guide the identification of the most likely and serious risks. Risk matrixes are revised at intervals specified in the risk plan in order to accurately reflect threats and weaknesses, which change over time. Businesses also use feedback from employees and clients to assess risk. This information may be supplied by satisfaction surveys and complaints, as well as observation of work environments (CNA, 2014). Employees and clients who are closest to the work being done within the organization often have the best view of unexpected events, causes, and possible ways to reduce risk. Documentation and communication of unexpected events are essential to effective assessment of the organization’s risks. Formally tracking the details of unexpected events helps the organization to identify weaknesses in practices and policies to avoid future risks and improve quality. A common way to track an unexpected event is to use an incident report, which is a document of objective information collected as soon as possible after an adverse event or near miss for the purpose of tracking data, ensuring appropriate follow up, and learning how to reduce or eliminate risk of reoccurrence (Levinson, 2012). Near misses are included in incident reporting because they tell an important story, without harm to the client or worker, to prevent harm in the future. A staff member who is involved in an adverse event or near miss or who is the first to become aware of the event usually completes the incident report together with his or her supervisor (see Exhibit 11.2). The risk manager or risk team reviews the details of the incident report. They monitor these reports for trends. It is vital that health care leaders create a culture in which employees feel comfortable communicating when things do not happen as planned. An organization’s policies should guide how and when incident reports are completed. EXHIBIT 11.2. Dos and Don’ts for Incident Reporting GUIDELINES FOR INCIDENT REPORTING Do ■ Report to supervisor ■ Complete as soon as possible ■ Provide facts and statements ■ Assist with client concerns Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Do Not ■ Wait ■ Blame ■ Document opinions 112 SECTION II. Organizational Planning and Culture Risk analysis After the organization has determined its most critical risks, the risk manager or risk team guides the identification of possible causes, effects, and solutions through risk analysis. During this step, the risk manager or team seeks to understand the underlying systemic root causes of the problem. Health care teams often use a root cause analysis, which is a tool used by a team to determine all system factors directly associated with an adverse event or near miss with the aim of developing an action plan to reduce risk (Occupational Safety and Health Administration, 2016; U.S. Department of Veterans Affairs, 2015). A cause-and-effect (“fishbone”) diagram provides a visual tool for the root cause analysis (CMS, n.d.; see also Figure 11.3). Essentially the team continues to ask “why” until all core reasons for a problem are recognized. When the root causes are known, the organization can plan ways to respond to the risk. The Joint Commission (2017a) provides a framework for root cause analysis to guide health care organizations. Risk analysis is vital to effective risk management and should include input from those directly connected to the risk or problem. Risk response Organizations respond to risk in 4 ways: (1) mitigating or reducing, (2) eliminating or avoiding, (3) accepting, or (4) transferring the risk (ASHRM, 2006a; CDC, 2006). Careful assessment and analysis determine the best response. Ideally, the organization will eliminate risks completely. When this is not possible, it will reduce the risk as much as possible. Strategies to eliminate and mitigate risk include adopting policies and procedures, documentation and reporting processes, environmental adaptations, staff training and competencies, communication, and planning (Clarke, 2000). When a risk cannot be avoided or reduced, the organization either accepts or transfers the risk. When risk is accepted, the organization decides that it can tolerate this amount of risk within its daily operations. The risk is known and will continue to be monitored as part of risk management. When an unavoidable risk cannot be tolerated, the organization transfers the risk. This is often done through the purchase of insurance (Dickson, 1995). For example, because the possibility of clinical errors and litigation may not be eliminated entirely, an organization will often carry malpractice insurance for the business and its professional employees like occupational therapy practitioners. The risk of liability is shared through the insurance to minimize the negative impact on the function of the organization. Risk reporting and monitoring How does an organization know if its risk management efforts are working? Organizations continue to monitor identified risks and communicate about risk with internal stakeholders (e.g., employees) and external stakeholders (e.g., health care consumers). Information shared with stakeholders should include the risk management activities that have been undertaken for identified risk and data that have been tracked to assess success of these activities. The risk report will include data such as unexpected events, reportable outcomes (e.g., quality key indicators, claims), policy changes, credentialing procedures, staff training, and patient safety activities. It is also essential for the organization to continue to monitor and report new risks as contextual factors influencing the delivery of care. This step in risk management includes quality improvement. Just as risk managers use techniques to assess, analyze, and control risk, quality improvement specialists use special tools to monitor quality, track and report data, and test possible solutions. When a plan of action is established by the root cause analysis, a model called the Plan–Do–Study–Act Cycle (PDSA), is commonly used to test solutions (Morelli, 2016; W. Edwards Deming Institute, 2017). Health care leaders use this team approach to test a solution for a problem in a similar way to the scientific method of testing a hypothesis (Gorenflo & Moran, 2010). To learn more about PDSA, visit the Minnesota Department of Health website (https://bit.ly/2MeZOuq). Case Example 11.1 illustrates risk management. CASE EXAMPLE 11.1. Home Health Agency Risk Management In home health, a risk often addressed is the clinical risk of client injury related to falls. In this case example, consider the risk management process used by a home health agency attempting to decrease the risk of client falls. Risk plan The agency has a written risk plan, which includes its philosophy that patient safety is the responsibility of every employee. Risk management goals include minimizing client risk of injury and hospitalization in order for the client to remain at home, in keeping with the agency’s mission. The risk plan identifies the risk officer as the primary responsible person for risk management activities. The risk officer reports to the chief financial officer and communicates with clinical managers and the quality improvement department during risk management activities. Risk assessment The risk officer at the agency routinely tracks the rate of home health clients who receive emergency care for an injury from a fall while on service with the agency. The agency has reported a higher rate of client injury from falls than the national average over the past 2 years. This is a negative outcome for the organization. Because of frequent client falls and the potentially severe negative impact on the agency’s ability to fulfill its mission, the administration has rated this risk as a high priority when completing an annual risk matrix. The agency had planned several opportunities for staff education on fall prevention. The risk officer reviews all incident reports completed by agency employees. Recently, an incident report was completed by a clinical manager when a client fell during a visit from the home health aide (see Exhibit 11.3). Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] (Continued) 113 CHAPTER 11. Risk Management and Contingency Planning CASE EXAMPLE 11.1. Home Health Agency Risk Management (Cont.) EXHIBIT 11.3. Sample Risk Report HOME HEALTH AGENCY INCIDENT REPORT Date and Time of Event: 6/20/2019 10:05 a.m. Type of event: Witnessed fall Client Name: Mr. M Client ID: 000000000 Location of event: Client’s home, 123 ABC Street Employees involved: Anna, home health aide Other witnesses: Client’s wife, Mrs. M DESCRIPTION OF EVENT Home health aide arrived at patient’s home to assist him with showering. Client accessed his shower and participated in bathing while seated on his shower chair. When client finished shower, aide turned the water off and helped client to dry his body as much as possible while seated on shower chair. Client turned his body on shower chair to prepare to exit shower using the method that he had been using in previous sessions with occupational therapy practitioner. Client stood with assistance from aide and placed his hands on his walker while aide reached for the client’s robe. Client let go of the walker with both hands to fix his hair while looking in the mirror and lost his balance. Home health aide was able to place hands on client’s shoulder and torso to help ease his descent to the floor. Condition of client before event: Client, seated in a chair in his bedroom, presented with intact mental status. He reported feeling fatigued after visiting the doctor this morning for a routine medical exam but asked to shower today as planned. Condition of client after event: Client reported pain in his right hip while lying on the floor in the bathroom. He began to sit up from the floor but then reclined again, reporting right hip pain was severe. Client did not hit his head or lose consciousness. Was injury sustained? Yes—right hip pain Did client require emergency care? Yes IMMEDIATE FOLLOW-UP TO THE EVENT Aide stayed with client while client’s wife called 911. Paramedics arrived and transported client to emergency room for assessment of right hip pain. Aide notified supervisor, the nurse, and the occupational therapy practitioner on Mr. M’s case about this fall. Dr. S was notified of fall, hip pain, and transport to emergency room. PLAN OF ACTION Case manager will attempt to contact client’s wife this evening (6/20/19) and the hospital as needed, to determine the status of Mr. M. Case manager, occupational therapist, home health aide, and clinical manager will review Mr. M’s home health aide care plan and revise as needed depending on his ability when he returns home. Occupational therapist plans to reassess fall risk and educate client and caregiver on fall prevention during ADLs. Team plans to continue interdisciplinary communication related to client safety. Additional Comments: On 6/20/19, supervisor received confirmation from hospital that client was admitted to hospital with a right hip fracture. Completed by: B. Supervisor Date: 6/20/19 Reviewed by: Risk Manager Date: 6/21/19 Note. ADLs = activities of daily living. Risk analysis A small group, including the risk officer, clinical manager, occupational therapy practitioner, physical therapist, nurse, and home health aide, met to analyze the details of this client’s fall, which caused a hip fracture. A root cause analysis was performed (see Figure 11.3). The risk officer facilitated the meeting, ensuring that everyone involved understood that the focus of the meeting was to identify possible system causes, not to assign blame. The home health aide reported feeling rushed during her day because she had a high caseload. She had been asked to cover for another aide who was sick. The aide reported that she was running behind schedule when she arrived at the client’s home. Despite rushing, she had checked that the bathroom floor was dry and that a towel and robe were within reach before the client exited the shower. The occupational therapy practitioner reported that this client’s ability to transfer to and from the shower chair had declined in the past week. The practitioner left a message for the assigned home health aide but did not realize that this aide was out sick. The nurse mentioned that the client had a loss of balance as he stepped onto the scale during her visit, but he did not fall. She did not report this to the team because the client was not injured. The physical therapist reported that she was attempting to schedule an evaluation of this client, but had not been able to reach him. She did not notify the team members. She reported that she did not have time because many clients were waiting to be evaluated. The root cause analysis determined that staffing issues, communication issues, and lack of training on reporting near misses were system causes (Figure 11.3). Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] (Continued) 114 SECTION II. Organizational Planning and Culture CASE EXAMPLE 11.1. Home Health Agency Risk Management (Cont.) FIGURE 11.3. Example of root cause analysis for a witnessed fall. Di d to not k rep no or w t Processes Near fall not reported Environment Limited space in client’s bathroom Delay in therapy evaluations s ue affi St ss gi n Lack of team communication No gait belt available Lack of employee planning time Client sustained hip fracture during witnessed fall No additional coverage for sick staff member Equipment/Resources Staff/People Risk response and monitoring Based on the analysis, the risk officer and administration created an action plan to mitigate staffing issues and eliminate breakdowns in team communication and reporting processes. The action plans included revision of procedures and staff education on when and why to report near misses in addition to adverse events. The risk officer shared information about client fall outcomes and trends in staff reporting at monthly team meetings and worked closely with clinical managers to assure staffing needs were met. The quality improvement department audited charts to assess the implementation of best practices in fall prevention and team communication. Staff and client surveys included questions about the success or need to improve in these targeted areas. The agency’s rate of client injury from falls decreased over the course of 1 year, but the agency again included this area of risk in the next annual risk matrix because of the crucial impact of client falls on the agency’s ability to fulfill its mission. Review Questions 1. 2. 3. How did the home health agency determine that the risk of client injury from falls should be a priority? How did the root cause analysis help the group (which included a risk manager) to determine the agency’s risk response for client injury from falls? What did the agency do to continue monitoring this risk? Contingency Planning When risks become reality, businesses follow a contingency plan, or a predetermined course of action to guide an orga­ nization’s response to and recovery from a negative or unexpected event in order to resume normal operation (CDC, 2008). A contingency plan is similar to the idea of a “Plan B” that we may use in our everyday lives. It is not the first or best plan, but it is necessary when “Plan A” will not work. Contingency plans plot the course of action for an organization to respond to and recover from an unexpected negative event in order to resume normal operation (CDC, 2008). These deliberate plans are developed collaboratively through careful assessment of risk and resources. Contingency plans are documented at a policy level so that everyone in the organization is aware of the details. Policymakers often include a decision tree to guide staff when carrying out the plan (Turoff et al., 2013). Plans should be clear, simple to follow, and realistic (World Health Organization [WHO], 2012). The plan must be established, written, shared, and tested well in advance of the possible trigger for it to be effectively implemented. Testing the plan includes practice. First, a small group of administrators, usually including a risk manager, implements tabletop exercises to discuss the execution of a contingency plan for a hypothetical emergency. The goal of a tabletop exercise is to find out how the contingency plan will be implemented and discuss what worked and did not work within an informal environment (U.S. Department of Homeland Security [DHS], 2013). The group can then make corrections before the plan is shared with all staff. Once the plan is approved and staff is trained in the emergency preparedness procedures, an organization prudently assesses staff members’ knowledge and confidence regarding the plan (Turoff et al., 2013). At this time, larger scale Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 11. Risk Management and Contingency Planning 115 operations-based exercises are completed. During operations- based exercises, including drills, employees respond to a hypothetical emergency by enacting their roles and responsibilities listed within the contingency plan (DHS, 2013). Outside entities (e.g., first responders) may or may not be included in the exercise. Operations-based exercises are intended to assess the ability for the members of the organization to collaborate and execute the contingency plan. The drills or exercises can pinpoint areas that require change or additional training that is needed to facilitate best practices during a real emergency. The contingency plan must be monitored and updated on an ongoing basis to ensure that it works as risks and resources change. Routine staff training and practice must accompany contingency planning (Turoff et al., 2013). Organizations make contingency planning part of the organizational routine by including staff members in planning, making policies and procedures accessible, training staff regularly, and practicing drills and simulations. Professional organizations (e.g., Joint Commission, CMS, Commission on Accreditation of Rehabilitation Facilities, WHO) offer specific resources to guide health care organizations as they develop contingency plans for emergencies. PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Review Questions Managing Risks in Practice 1. What are the 5 strategies of risk management? 2. Which tools are used in risk management and quality improvement? Briefly describe how they work. 3. How do contingency plans fit within an organization’s risk management program? In clinical practice, occupational therapy practitioners continuously monitor for client safety risks. Still, near misses and adverse events occur in occupational therapy practice, most often during interventions (Mu et al., 2006). Clinical risks for occupational therapy clients include falls, injuries, Occupational therapy practitioner Aideen Gallagher (2013) proposed that successful participation in occupations “demands an engagement with risk” (p. 338). Occupational scientists have studied the connection between risk and occupations (Dennhardt & Rudman, 2012). The American Occupational Therapy Association (AOTA; 2014) supports organization- or systems-level practice in occupational therapy in the Occupational Therapy Practice Framework: Domain and Process (OTPF–3). Businesses, like occupational therapy clients, must encounter risk in order to grow. As experts in the transactional relationships among person, environment, and occupations, occupational therapy practitioners can adeptly understand and respond to risk in both their practice and leadership roles (Gallagher, 2013). Several occupational therapy skills place occupational therapy practitioners in a prime position to successfully manage risks (see Table 11.2). Practitioners aim to maximize performance and participation whether leading clients, staff, or a business. TABLE 11.2. Occupational Therapy Skills and Risk Management Strategies OCCUPATIONAL THERAPY SKILL RISK MANAGEMENT STRATEGY RELATIONSHIP Systems-oriented approach Risk assessment Occupational therapy practitioners understand how client factors, skills, patterns, and contexts connect and how the mission, needs, resources, threats, and opportunities of an organization connect to effectively plan interventions and monitor outcomes. Activity analysis Risk analysis Occupational therapy practitioners analyze the specific skills required for an activity and the root causes of a problem to plan for improvement. Knowledge of performance patterns Risk response Occupational therapy practitioners understand that routines can support or limit performance for a client or an organization. By learning the routines of members of the organization, they can help to determine and embed best practices in the organizational routine. Clinical reasoning and therapeutic use of self Risk reporting Occupational therapy practitioners use theory and strong interpersonal skills to facilitate collaborative therapeutic relationships with clients and to enable a culture of safety within an organization. Adaptation Contingency planning Occupational therapy practitioners naturally adapt process, tools, and environment to promote client engagement in occupation and to create and implement contingency plans in response to conditions that threaten an organization’s operations. WFOT (2016) and AOTA (2015) have formally affirmed the role of occupational therapy in disaster risk reduction. Note. AOTA = American Occupational Therapy Association; WFOT = World Federation of Occupational Therapists. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 116 SECTION II. Organizational Planning and Culture and adverse reactions to modalities and other treatments. Strategies to reduce clinical risk include attending to clients’ needs and conditions; assessing the environment of care; and adherence to professional standards, state practice acts, and organizational policies and procedures (CNA, 2017; Ranke & Moriarty, 1997). Evidence supports a connection between communication and risk management in occupational therapy practice (Atwal et al., 2011; Mu et al., 2011). Occupational therapy practitioners’ communication skills are critical to minimizing risks and promoting best practice strategies. Practitioners must also consider other types of risk in practice, including legal risks. Adherence to standards of care and accurate documentation can help clinicians to reduce legal risk. Clinicians may decide to share the risk of litigation by purchasing liability insurance. Two profes­sional liability companies, CNA and Healthcare Providers Service Organization, reported that malpractice claims against occupational therapy practitioners from 2006 through 2015 most frequently occurred in outpatient clinics (52%), followed by patient homes (18%) and aging services facilities (14%; CNA, 2017). Some occupational therapy practitioners may be insured through their employer and should know the details about the coverage provided. Independent contractors must be aware of the details of agreements with organizations and regulatory standards that apply specifically to contractors. Working in a world of advancing technology, practitioners must also consider technology risks related to patients’ protected health information and use of social media. For Additional Learning For additional learning, see Chapter 53, “Professional Liability Insurance.” Occupational therapy practitioners also use contingency planning in their practice. A simple contingency plan may be to modify a treatment plan because space is not available or a client is having too much difficulty with the planned intervention. When employed within an organization, occupational therapy practitioners may be part of contingency plans that are built into the agency’s policies. These plans can include emergency situations within the work setting or community, weather situations, and a shortage of resources. Managing Risks in Supervision, Management, and Organizational Leadership Occupational therapy practitioners who provide supervision to students, occupational therapy assistants, and aides must consider risks in the practice of these individuals, as well as their own. Failure to supervise according to the profession’s standards and licensure requirements creates risks for both occupational therapy clients and practitioners. Occupational therapy practitioners who own their own practice or manage a department must consider additional financial, strategic, operational, and human capital risks. Occupational therapy managers and practice owners have additional layers of responsibility regarding risk management. As leaders, they are likely to be directly involved with managing adverse events, strategic partnerships, billing for services, and ensuring compliance with regulatory standards. These individuals are also involved in, and sometimes solely responsible for, hiring and terminating staff. They must abide by regulations such as those set by the Americans With Disabilities Act (P. L. 101–336). Occupational therapy leaders support a culture of safety within their settings when they facilitate communication, standardized processes, competency checks, and a dedicated reporting system with their teams (Mandel, 2017; Mu et al., 2011). Occupational therapy managers and leaders also use contingency planning when addressing the potential of events not going as planned. For example, a manager may temporarily partner with a contract staffing agency to keep a department operating smoothly despite a staffing shortage, or a private practice owner could develop an alternative plan to continue serving clients during a local community disaster. Review Questions 1. How do the skills of the occupational therapy practitioner transfer to successful use of risk management strategies? 2. Which types of risk are present in occupational therapy practice and management? 3. What are some examples of risks that an occupational therapy manager or organizational leader might encounter? SUMMARY Health care organizations implement risk management strategies to ensure the ability to carry out their mission. These strategies include planning, assessing, analyzing, responding, monitoring, and reporting. The organization develops contingency plans for instances when risk cannot be avoided or controlled in order to minimize interruption to its operations. Occupational therapy practitioners manage risks, regardless of their roles within an organization. The skill set of occupational therapy professionals, including holistic assessment, activity analysis, knowledge of performance patterns, ability to adapt, and clear communication, naturally facilitates risk management, contingency planning, and quality improvement at an organizational level. See Case Examples 11.2 and 11.3 for examples of managing risk. Appendix 11.A, “Risk Management Resources,” provides additional resources for risk management and contingency planning. ❖ Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 11. Risk Management and Contingency Planning 117 CASE EXAMPLE 11.2. Julia: New Private Outpatient Practice Julia is an occupational therapist who has recently opened a private outpatient occupational therapy practice. The business is located in a unit of an office building in a small suburban town. There is another outpatient therapy practice in town that provides physical therapy and speech– language pathology services, in addition to occupational therapy. Julia’s specialty, driver rehabilitation, has been well-marketed with referral sources and within the community. Julia employs 1 additional occupational therapist and 1 part-time receptionist. Julia had worked as an occupational therapist in several outpatient centers prior to opening her own business. She was familiar with strategies to ensure best practice and avoid clinical patient safety risks, but her entrepreneurial pursuit invited new, additional risks. When preparing to open the practice, Julia needed to decide on a strategic plan to focus the direction of the business. This included branding, determining competition in the area, and marketing. She also needed to ensure that she had the financial resources and assistance for the business to get started and continue its mission. She consulted a financial manager regarding billing processes. Her ongoing attention to financial risk is required for successful operations. As Julia planned to hire staff, it was necessary to consider how she would conduct credentialing and fair employee practices. It is necessary for Julia to address liability risk through adherence to best practices and the purchase of insurance. Review Questions 1. 2. 3. Which types of risk are evident in this case example? Can you think of other risks that would likely be present for a new private occupational therapy practice? How is Julia responding to the risks that she has identified in starting a new practice? What other resources could she use in her risk response? Julia has done her best to plan for the business to operate smoothly. Can you think of any unforeseen circumstances that could threaten the practice? How might Julia use contingency planning to ensure normal operations if these circumstances occur? CASE EXAMPLE 11.3. Managing Risk in School Settings Occupational therapy practitioners who work across practice settings are exposed to risks. In the school setting, aggressive student behaviors, including hitting, kicking, and pinching, are potential risks that should be addressed. In this example, a team of professionals attempts to reduce the aggressive behaviors of a child to minimize the risk of student and staff injury. The risk plan of the school specifies that all employees are responsible for promoting a safe and effective learning environment. Teachers communicate with the educational team, including the occupational therapy practitioner, physical therapist, speech language pathologist, school counselor, and a board-certified behavioral analyst (BCBA), and they report directly to the principal. Teachers track aggressive behaviors in the classroom. Since the beginning of the school year, there has been a high frequency of aggressive behaviors reported. The educational team has participated in professional development activities to decrease aggressive behaviors in the classroom as well as various preventive classroom management strategies. Recently, Student A hit Student B while traveling between classrooms. Student B had a bruise on his arm after the incident. He went to the nurse and his parents were called. An incident report was completed. The teacher and all members of the educational team met to analyze details of this adverse event. The teacher reported that the routine class schedule was disrupted due to a morning assembly. The occupational therapy practitioner reported that a sensory assessment of student A was in progress and that sensory concerns might be raised. The BCBA also noted that the behavioral plan was not implemented during transition by the classroom aide. The group performed a root cause analysis to determine the underlying system factors, including limited planning for change in daily schedule, decreased communication among staff regarding the behavioral plan, and limited time to complete full assessments. The group created an action plan to reduce the risk of injury from aggressive behaviors in the future. The action plan included completion of sensory assessment to assess tactile defensive or body awareness concerns and a review and further education about the behavior plan by the BCBA for the entire team; a new policy was instituted whereby the administration would email all staff members about schoolwide events at least 2 days in advance. In addition, the entire team attended a professional development series. To report and continue monitoring the risk of injury from aggressive behaviors, team members met weekly to review all instances of aggressive behaviors in the classroom. The BCBA and occupational therapy practitioners completed classroom management assessments to provide information about behavioral and sensory strategies in the classroom. These assessments are monitored and shared, with the staff members involved, at least monthly. Review Questions 1. 2. The steps of risk management (i.e., risk plan, assessment, analysis, response, reporting or monitoring) can be observed through this case study. List the events in the case study that correspond with each step in the risk management process. What commonalities and differences do you notice between this case example in a school setting and examples of risk management in a health care setting? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 118 SECTION II. Organizational Planning and Culture LEARNING ACTIVITIES 1. Consider risks in your own routine. How do you recognize and respond to them? Complete a root cause analysis of a problem that you may be experiencing in your routine. Use a fishbone diagram. 2. Search the OTPF–3 for aspects of the profession’s domain and process that relate to risk management. Read the Occupational Therapy Code of Ethics (2015) (AOTA, 2015). How do occupational therapy leaders uphold each principle through the process of risk management? 3. Consider various occupational therapy practice settings. What types of unique risk would you expect to find in certain practice settings? Are there risks that may be present across all practice settings? 4. Invite a panel of clinicians and administrators from local practice settings to the classroom. Engage students in a discussion with this panel about the panel members’ experiences of risk management, safety, and quality improvement. 5. During a fieldwork experience, request to meet with someone who holds a dedicated risk management position within the organization or attend a risk management meeting. 6. Conduct a mock risk management committee meeting for a hospital. Consider which professions would be represented, including occupational therapy. Draft a risk management statement, including a brief description with a list of the people responsible for managing risk. ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ ■ ■ ■ ■ B.3.7. Safety of Self and Others B.5.1. Factors, Policy Issues, and Social Systems B.5.3. Business Aspects of Practice B.5.7. Quality Management and Improvement B.7.1. Ethical Decision Making. REFERENCES Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 72121005. https://doi.org /10.5014/ajot.2018.72S217 American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. https://doi.org/10.5014/ajot.2014.682006 American Occupational Therapy Association. (2015). Occupational therapy code of ethics (2015). American Journal of Occupational Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014 /ajot.2015.696S03 American Society for Healthcare Risk Management. (2006a). Enterprise risk management. Part one: Defining the concept, recognizing its value. Retrieved from http://www.ashrm.org/pubs/files /white_papers/ERMmonograph.pdf American Society for Healthcare Risk Management. (2006b). Enterprise risk management. Part two: Getting an ERM program started. Retrieved from http://www.ashrm.org/pubs/files/white _papers/ERMmonograph.pdf American Society for Healthcare Risk Management. (2006c). Enterprise risk management. Part three: The role of the chief risk officer (CRO). Retrieved from http://www.ashrm.org/pubs/files/white _papers/ERMmonograph.pdf American Society for Healthcare Risk Management. (2014). Enterprise risk management: A framework for success. Retrieved from http://www.ashrm.org/pubs/files/white_papers/ERM-White -Paper-8-29-14-FINAL.pdf American Society for Healthcare Risk Management. (2016). Enterprise risk management. Retrieved from http://www.ashrm.org /resources/pdf/ERM-Tool_final.pdf American Society for Healthcare Risk Management of the American Hospital Association. (2007). Different roles, same goal: Risk and quality management partnering for patient safety. Journal of Healthcare Risk Management, 27, 17–23, 25. https://doi.org/10.1002 /jhrm.5600270205 Americans With Disabilities Act, Pub. L. 101–336, 42 U. S. C. § 12101 (1990). Atwal, A., Wiggett, C., & McIntyre, A. (2011). Risks with older adults in acute care settings: Occupational therapists’ and physiotherapists’ perceptions. British Journal of Occupational Therapy, 74, 412–418. https://doi.org/10.4276/030802211X13153015305510 Centers for Disease Control and Prevention. (2006). CDC unified process practices guide: Risk management. Retrieved from https:// www2a.cdc.gov/cdcup/library/practices_guides/CDC_UP_Risk _Management_Practices_Guide.pdf Centers for Disease Control and Prevention. (2008). CDC unified process practices guide: Contingency planning. Retrieved from https:// w w w2.cdc.gov/cdcup/librar y/practices_guides/CDC _UP _Contingency_Planning_Practices_Guide.pdf Centers for Medicare and Medicaid Services. (n.d.). How to use the fishbone tool for root cause analysis. Retrieved from https://www .cms.gov/medicare/provider-enrollment-and-certification/qapi /downloads/fishbonerevised.pdf Centers for Medicare and Medicaid Services. (2007). Basics of risk analysis and risk management. HIPAA Security Series 2(6). Retrieved from https://www.hhs.gov/sites/default/files/ocr/privacy /hipaa/administrative/securityrule/riskassessment.pdf Clarke, C. (2000). Risk management: A user guide. British Journal of Occupational Therapy 63, 529–531. https://doi.org/10.1177 /030802260006301104 CNA. (2014). Principles of healthcare risk management. Healthcare Perspective Issue 1. Retrieved from http://www.hpso.com /Documents/pdfs/Principles_of_Healthcare_Risk_Management _-_2014-1.pdf CNA. (2017). Occupational therapy claim report: A guide to identifying and addressing professional liability exposures. Retrieved from http://www.hpso.com/Documents/pdfs/CNA_CLS_OT_032917 _CF_PROD_ONLINE_040417_SEC.pdf Dennhardt, S., & Rudman, D. L. (2012). When occupation goes “wrong”: A critical reflection on risk discourses and their relevance in shaping occupation. In G. E. Whiteford & C. Hocking (Eds.) Occupational science: Society, inclusion, participation (pp. 117–133). West Sussex, UK: Blackwell. https://doi.org/10.1002/9781118281581.ch9 Dickson, G. (1995). Principles of risk management. Quality in Health Care, 4, 75–79. Retrieved from https://www.ncbi.nlm.nih .gov/pmc/articles/PMC1055293/pdf/qualhc00016-0003.pdf Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 11. Risk Management and Contingency Planning ECRI Institute. (2014). Patient safety, risk, and quality. Retrieved from https://www.ecri.org/components/HRC/Pages/RiskQual4.aspx Gallagher, A. (2013). Risk assessment: Enabler or barrier? British Journal of Occupational Therapy. https://doi.org/10.4276/030802 213X13729279115095 Gorenflo, G., & Moran, J. W. (2010). The ABCs of PDCA. Retrieved from http://www.phf.org/resourcestools/Documents/ABCs_of _PDCA.pdf Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press. https://doi .org/10.17226/9728. The Joint Commission. (2017a). A framework for conducting a root cause analysis and action plan in response to a sentinel event. Retrieved from https://www.jointcommission.org/framework _for_conducting_a_root_cause_analysis_and_action_plan/ The Joint Commission. (2017b). Sentinel event policy and procedures. Retrieved from https://www.jointcommission.org/sentinel _event_policy_and_procedures/ Levinson, D. R. (2012). Hospital incident reporting systems do not capture most patient harm (Office of Inspector General Report OEI-06-09-00091). Retrieved from https://oig.hhs.gov/oei /reports/oei-06-09-00091.pdf Makary, M. A., & Daniel, M. (2016). Medical error—The third leading cause of death in the US. BMJ, 353. https://doi.org/10.1136 /bmj.i2139 Mandel, C. (2017). Patient safety is everyone’s business. Journal of Medical Radiation Sciences 64, 161–162. https://doi.org/10.1002 /jmrs.241 Morelli, M. S. (2016). Using the Plan, Do, Study, Act model to implement a quality improvement program in your practice. American Journal of Gastroenterology, 111, 1220–1222. https:// doi.org/10.1038/ajg.2016.321 Mu, K., Lohman, H., & Scheirton, L. (2006). Occupational therapy practice errors in physical rehabilitation and geriatrics settings: A national survey study. American Journal of Occupational Therapy, 60, 288–297. https://doi.org/10.5014/ajot.60.3.288 Mu, K., Lohman, H., Scheirton, L. S., Cochran, T. M., Coppard, B. M., & Kokesh, S. R. (2011). Improving client safety: Strategies to prevent and reduce practice errors in occupational therapy. American Journal of Occupational Therapy, 65, e69–e76. https://doi.org/10.5014/ajot.2011.000562 119 National Patient Safety Foundation. (2015). Free from harm: Accelerating patient safety improvement fifteen years after To Err Is Human. Retrieved from www.npsf.org/free-from-harm National Safety Council. (2013). Near miss reporting systems. Retrieved from https://www.nsc.org/Portals/0/Documents/Work placeTrainingDocuments/Near-Miss-Reporting-Systems.pdf Occupational Safety and Health Administration. (2016). The importance of root cause analysis during incident investigation. Retrieved from https://www.osha.gov/Publications/OSHA3895.pdf Ranke, B. A. E., & Moriarty, M. P. (1997). An overview of professional liability in occupational therapy. American Journal of Occupational Therapy, 51, 671–680 https://doi.org/10.5014 /ajot.51.8.671 Ross, R. S. (2012). Guide for conducting risk assessments (NIST Special Pub. 800–30). Retrieved from https://www.nist.gov /publications/guide-conducting-risk-assessments Turoff, M., Hiltz, S. R., Bañuls, V. A., & Van Den Eede, G. (2013). Multiple perspectives on planning for emergencies: An introduction to the special issue on planning and foresight for emergency preparedness and management. Technological Forecasting and Social Change, 80, 1647–1656. Retrieved from https://doi .org/10.1016/j.techfore.2013.07.014 U.S. Department of Homeland Security. (2013). Homeland security exercise and evaluation program. Retrieved from https://www .fema.gov/media-library-data/20130726-1914-25045-8890 /hseep_apr13_.pdf U.S. Department of Veterans Affairs. (2015). Glossary of patient safety terms. Retrieved from https://www.patientsafety.va.gov /professionals/publications/glossary.asp W. Edwards Deming Institute. (2017). PDSA cycle. Retrieved from https://deming.org/explore/p-d-s-a World Federation of Occupational Therapists. (2016). Position statement: Disaster risk reduction. Retrieved from http://www.wfot .org/ResourceCentre.aspx World Health Organization. (2011). Topic 6: Understanding and managing clinical risk. In The multi-professional patient safety curriculum guide. Retrieved from http://www.who.int/patient safety/education/curriculum/who_mc_topic-6.pdf World Health Organization. (2012). Guidance for contingency planning rom (DRAFT). Retrieved from http://www.searo.who.int /entity/emergencies/cpforwebsite.pdf?ua=1 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 120 SECTION II. Organizational Planning and Culture APPENDIX 11.A. RISK MANAGEMENT RESOURCES Videos ■ Risk Management: Chris Davenport at TEDxMileHigh Online ■ The Joint Commission on Root Cause Analysis (https:// ■ bit.ly/2AWbtLx) The Joint Commission provides a template to guide organizations when analyzing an event and developing an action plan. The Minnesota Department of Health: Plan–Do–Study– Act (PDSA; https://bit.ly/2MeZOuq) The Minnesota Department of Health explains the PDSA cycle that is often used when an organization wishes to improve performance. ■ ■ ■ (https://youtu.be/zyet9fPS24k) In this TED Talk, skier Chris Davenport relates risk and risk management involved in skiing to risk and risk management within an organization. Cause and Effect Diagram (https://youtu.be/mLvizyDFLQ4) Brief video highlights how health care organizations use cause-and-effect diagrams. A sample diagram is created to address improvement in handwashing. Root Cause Analysis Training for Health Care: Root Cause Analysis (https://youtu.be/4bldoFN5a1g) This 54-minute video training by Rosemary Emmons aims at making root cause analyses in health care systems effective. Quality Improvement in Health Care: https://youtu.be /jq52ZjMzqyI This brief video depicts historical overview of quality improvement in health care. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Marketing Strategies and Analysis 12 Jessica McMurdie, OTR/L LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Understand the basic concepts of marketing strategies and the tactics used to market occupational therapy services or products, Understand how market research helps to identify and locate the potential needs for services, Describe the 3 primary target markets for occupational therapy practitioners, Learn why market analysis is important for assessing the success of a marketing plan, Define a unique selling proposition and understand the importance of differentiating from competitors when marketing a product or service, Understand the basic structure of a marketing plan and the purpose of incorporating business strategies to track and measure the effectiveness of the marketing plan, Describe how marketing trends and technologies can increase awareness of services and brand promotion through digital communication and connectivity, and Describe the use of social media in marketing and the various channels in which occupational therapy can be promoted. ■ ■ ■ ■ ■ ■ ■ KEY TERMS AND CONCEPTS • • • • • • • • Conversion strategy Customer experience Description of services Environmental assessment Evangelism Implementation Key performance indicators Market analysis • • • • • • • • Market position Marketing Marketing mix Marketing research Marketing plan Mission statement Online marketing strategy Organizational assessment OVERVIEW T he successful promotion of occupational therapy is directly related to the practice and the art of marketing. Occupational therapy practitioners have many opportunities to implement marketing techniques to achieve their organization’s business success while concurrently delivering expected clinical outcomes and providing a remarkably positive patient experience. In the current health care environment of declining reimbursements and the myriad choices that consumers are presented with, it is crucial that • • • • • • • • Outcome marketing Positioning strategy Referral strategy Social media Target market Target marketing Unique selling proposition Vision statement occupational therapy managers adopt a marketing mindset to stay competitive and promote the value of occupational therapy in the greater health care marketplace. The job outlook for occupational therapy practitioners is projected to grow at a rate of 27% between 2014 and 2024. The average growth rate for all occupations is 7% (Bureau of Labor Statistics, 2017). Given the anticipated growth of the profession, a vast array of potential practice areas and marketing opportunities await occupational therapy practitioners across settings and patient populations. This chapter focuses on general Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.012 121 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Marketing Strategies and Analysis 12 Jessica McMurdie, OTR/L LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Understand the basic concepts of marketing strategies and the tactics used to market occupational therapy services or products, Understand how market research helps to identify and locate the potential needs for services, Describe the 3 primary target markets for occupational therapy practitioners, Learn why market analysis is important for assessing the success of a marketing plan, Define a unique selling proposition and understand the importance of differentiating from competitors when marketing a product or service, Understand the basic structure of a marketing plan and the purpose of incorporating business strategies to track and measure the effectiveness of the marketing plan, Describe how marketing trends and technologies can increase awareness of services and brand promotion through digital communication and connectivity, and Describe the use of social media in marketing and the various channels in which occupational therapy can be promoted. ■ ■ ■ ■ ■ ■ ■ KEY TERMS AND CONCEPTS • • • • • • • • Conversion strategy Customer experience Description of services Environmental assessment Evangelism Implementation Key performance indicators Market analysis • • • • • • • • Market position Marketing Marketing mix Marketing research Marketing plan Mission statement Online marketing strategy Organizational assessment OVERVIEW T he successful promotion of occupational therapy is directly related to the practice and the art of marketing. Occupational therapy practitioners have many opportunities to implement marketing techniques to achieve their organization’s business success while concurrently delivering expected clinical outcomes and providing a remarkably positive patient experience. In the current health care environment of declining reimbursements and the myriad choices that consumers are presented with, it is crucial that • • • • • • • • Outcome marketing Positioning strategy Referral strategy Social media Target market Target marketing Unique selling proposition Vision statement occupational therapy managers adopt a marketing mindset to stay competitive and promote the value of occupational therapy in the greater health care marketplace. The job outlook for occupational therapy practitioners is projected to grow at a rate of 27% between 2014 and 2024. The average growth rate for all occupations is 7% (Bureau of Labor Statistics, 2017). Given the anticipated growth of the profession, a vast array of potential practice areas and marketing opportunities await occupational therapy practitioners across settings and patient populations. This chapter focuses on general Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.012 121 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 122 SECTION II. Organizational Planning and Culture marketing concepts, the evolution of marketing frameworks for the 21st century, practical applications for promoting occupational therapy services, the key components of a marketing plan, trends in technology, and considerations for implementing best practices when marketing occupational therapy services. ESSENTIAL CONSIDERATIONS The American Marketing Association (2013) defined marketing as “the activity, set of institutions, and processes for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners, and society at large” (para. 1). Philip Kotler, a leading marketing expert, defined marketing as [T]he science and art of exploring, creating, and delivering value to satisfy the needs of a target market at a profit. Marketing identifies unfulfilled needs and desires. It defines, measures and quantifies the size of the identified market and the profit potential. It pinpoints which segments the company is capable of serving best and it designs and promotes the appropriate products and services. (Kotler Marketing Group, n.d., para. 1) Traditional marketing concepts have shifted from primarily focusing on product, price, placement, and promotion to a new framework based on providing value, meaning, and the careful analysis of what comprises an amazing customer experience. Occupational therapy managers must answer to this value-based mindset through a systematic marketing approach to meet the expectations, desires, and needs of clients in a consumer-driven market (Jantsch, 2011). Today’s consumers of health care have access to incredible amounts of information online, making them better educated and savvier than ever before. Market A target market is a specific group of consumers or clients at whom a company aims its products and services (Entrepreneur Small Business Encyclopedia, n.d.). Marketing research is the first step in identifying the specific target audience with whom to share expertise, provide services, or build a successful payer or referral relationship. In occupational therapy, there are 3 primary target markets: (1) clients and potential clients, (2) payers, and (3) referral sources or influencers. Clients and potential clients The first target market is composed of clients and potential clients who directly benefit from occupational therapy services. Some examples include adult patients recovering from an acute injury or neurological event, elderly patients in a skilled nursing facility (SNF) setting, or children with developmental delays who receive services at school or a community clinic. Payers The second target market consists of the payers, specifically commercial health insurance companies and government programs (e.g., Medicare, Medicaid, Departments of Labor and Industry). These payers reimburse facilities and practitioners for billable occupational therapy services, most commonly paid based on units of time, allowed amounts, level of complexity, and perceived value. Reimbursement for occupational therapy services may be reviewed for medical necessity, and it is essential for the practitioners’ documentation to prove that therapy is directly related to functional outcomes. Referral sources The third type of target market is referral sources or, in the context of social media, “influencers.” Referral sources are considered one of occupational therapy’s target markets because they are individuals or organizations that refer and recommend occupational therapy services as a solution for a client’s need or problem. According to Hootsuite.com, A social media influencer [italics added] is someone who wields that influence through social media. . . . The right influencer is someone who can reach your target audience, build trust, and drive engagement. They will create original, engaging content that is in line with their own brand. (Newberry, 2018, para. 6–7) For example, a pediatrician identifies a child with delayed visual motor skills during an annual checkup. As the primary care provider, the doctor refers this child to the occupational therapy clinic with whom he or she is familiar and has developed a referral relationship when coordinating the care of mutual patients. Marketing Mix Marketing mix, also called a promotional mix, refers to the tactical, controllable, and operational components of a marketing plan that may be combined to produce the desired response from the target market. The original marketing mix is most commonly known as the 4 Ps: product, price, place, and promotion. An extended marketing mix includes the addition of 3 Ps: people, process, and physical evidence/ environment (Bitner & Brooms, 1981, as cited in Hanlon, 2018; see Figure 12.1). The 7 Ps of the marketing mix are particularly relevant to service industries such as occupational therapy. The service offerings made to a client can be altered by varying the mix elements, which are explained below (Marketing Teacher, n.d.). ■ Product is defined as the “goods-and-services combina- ■ tion the company offers to the target market” (Kotler & Armstrong, 2010, para. 11). A product is commonly considered a tangible, physical item that one buys or sells, whereas a service, such as occupational therapy, is considered an intangible product. Price refers to the amount of money charged for a product or service that consumers exchange for the benefit of having or consuming that product (Kotler, 2000). Factors that influence the price of a service or product Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 12. Marketing Strategies and Analysis 123 FIGURE 12.1. The 7 Ps of marketing. Product Physical Evidence Price 7 Ps Marketing Mix Process Place People ■ ■ are overhead costs, such as rent and equipment, cost of materials, labor wages, the fair market value, and the market demand for the product or service. In the health care landscape, pricing of medical services is frequently predetermined by governing bodies or third-party payers. For example, occupational therapy practitioners in a contract arrangement with a payer abiding by the current allowed amounts, coding rules, and regulations ultimately drive the reimbursement structure and pricing. Place is the physical or virtual location where the goods and services are provided. For example, a hand clinic opens a new office in the same building as the town’s orthopedic surgery practice. The location is conveniently located for patients as well as strategically located to maintain an alliance and referral relationship between the 2 practices. Promotion details how to reach new clients and referral sources. Promotional strategies such as special offers are often used to grow the company’s client base by securing new clients and encouraging former clients to help generate new referrals. Promotional techniques are used to provide information, explain a problem and offer a solution, and persuade and influence the target market to convert prospects into future clients. Examples of promotional strategies include advertising, sales promotions, public relations, and personal selling. Modern marketing tactics are trending toward promoting products and Promotion ■ ■ ■ services through a form of personal selling via videos. Video promotion serves as a powerful tool to increase awareness and promote the value of occupational therapy. Effective video storytelling is authentic, compelling, and planned, yet not fully scripted and contains a defining moment with a combination of familiar and surprising elements (American Occupational Therapy Association [AOTA], 2017). People are the essential element to occupational therapy services because clients make judgments about the organization’s services based on the people representing the organization. It is essential for occupational therapy managers to recruit the right staff and hire those whose attitudes and behaviors align with the mission, vision, and culture of the company. Process refers to how the service is delivered. Processes are essential to delivering a consistent quality of care, especially when the care is provided by different people within the organization. A well-organized process with systems in place and clear communication fosters client loyalty and confidence in the company. Physical evidence or environment refers to the physical elements that convey an organization’s brand and affects how clients experience its services. Examples of physical evidence that affect clients’ impressions may start when they are viewing the organization’s website and continue as they enter the door and experience the organization’s atmosphere when participating in therapy. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 124 SECTION II. Organizational Planning and Culture EXHIBIT 12.1. Marketing Examples Advertising ■ ■ ■ ■ ■ ■ ■ Direct mail Print brochure Flyer/handout Magazine or journal advertisement Digital marketing Website Social media Sales Promotions ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Coupons Discounts Loyalty programs Gift certificates Referral incentives Subscriptions Company-branded items (e.g., pens, clothing, mugs) Gifts or treats Free screenings Giveaways Public Relations ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Testimonials Guest speakers Published research Authoring an article Case study Community events Health fairs Open house Networking meeting Interview/podcast Charitable events TV appearance Personal Selling ■ ■ ■ ■ ■ ■ ■ ■ ■ Personalized cards or gifts Attending seminars Networking events Forming business alliances Collaborating with other professionals Interacting with influencers through social media Writing a blog Hosting a YouTube channel Video storytelling Exhibit 12.1 provides examples of ways to promote occupational therapy to reach new clients and referral sources. Marketing Research Marketing research is the process of gathering, analyzing, and interpreting information about a market; about a product or service to be offered for sale in that market; and about past, present, and potential customers. Marketing research includes studying the characteristics, spending habits, location, and needs of the business’s target market, the industry as a whole, and the particular competitors within the industry (Entrepreneur Encyclopedia, n.d.). The ultimate objective of marketing research is to determine which segment of the market one is going to own or participate in and how to properly position one’s product within that segment (Marshall, 2014). A key component of marketing research is target marketing, which “allows you to reach, create awareness in, and ultimately influence the group of people most likely to select your products and services as a solution to their needs, while using fewer resources and generating greater returns” (Gandolf, 2017b; “The Target Market Profile”). Marketing research involves discovering commonalities found in the following 4 categories: (1) geographics, (2) demographics, (3) psychographics, and (4) behavior (see Exhibit 12.2). Market Position Establishing a solid market position involves defining an organization’s unique selling proposition or how its service is different, special, or unique as compared with competitors to influence the consumers’ perception of brand. To establish a strong position in the market, it is often advantageous EXHIBIT 12.2. Target Market Areas Geographics ■ ■ ■ ■ Location Size of the area Population density Climate zone Demographics ■ ■ ■ ■ ■ ■ Age Gender Education Income Family composition and size Language spoken Psychographics ■ ■ ■ ■ ■ ■ General personality Lifestyle Beliefs Rate of use Repetition of need Benefits sought Behaviors ■ General attitude ■ Needs and wants the customer seeks to fulfill ■ Level of knowledge, information sources, and technology used Source. Adapted from Gandolf (2017b). Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 12. Marketing Strategies and Analysis to create new markets, focus on a specific niche segment, or improve on a unique or superior service in an already established industry. Occupational therapy practitioners are at an advantage because they offer a unique skill set and can readily draw from their knowledge and experience base as experts within their field. EXHIBIT 12.3. Environmental Assessment Factors Sociocultural Trends ■ ■ ■ ■ ■ Market Management The 4 steps in market management are (1) market analysis, (2) planning, (3) implementation, and (4) monitoring. Planning An effective marketing plan provides the framework for creating goals and developing the specific marketing activities and strategies to support the growth and success of the business within a set time period. Key components of a marketing plan are listed in Exhibit 12.4 (Lavinsky, 2013). Language Education Values Beliefs Attitudes Demographic Information ■ ■ ■ ■ ■ ■ ■ Market analysis The first step in market management is market analysis, which is the use of assessment techniques to understand customers, markets, and marketing effectiveness (Kotler, 2003). The information gathered from market analysis research determines the details of the marketing plan. A competitive market analysis identifies the organization’s competitors and evaluates their strengths and weaknesses relative to those of the organization’s own services or product. A competitive market analysis equips the business to proactively anticipate competitive influences and potential issues, serving as a foundational strategy to stay ahead of the competition. The 2 approaches to conduct market analysis are (1) organizational assessment and (2) environmental assessment. An organizational assessment is a self-assessment of the organization’s strengths, weakness, available opportunities, and potential threats (see Case Example 12.1, “Conducting an Organizational Assessment”). An environmental assessment identifies the greater forces, changes, and trends in the environment (local, national, and international) that may affect occupational therapy practitioners’ business relationships with the target market and overall marketing strategy. An environmental assessment also examines sociocultural trends, economic issues, political issues, legal issues, and trends in technology. By anticipating these changes, one can take a proactive approach to position a product or service in response to the trends in the greater environment. An example of useful demographic information is when a hospital is determining the potential location of a new home health satellite clinic for older adults. On the basis of an environmental assessment, the hospital decides to locate the home health clinic within a community with highest concentration of people ages 65 years or older. A second example is how the economy and political climate can dramatically affect how health care services are accessed by patients and the level of reimbursement to providers (see Exhibit 12.3). 125 Population statistics Age Ethnicity Sex Education Income Labor force projections Economic Changes ■ ■ ■ ■ ■ ■ Overall economy Cost of living Financial markets Government spending Rising costs of health care Patient ability to pay for therapy services Political Issues ■ Commercial payer regulations ■ Federal regulations—awareness of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104–191) and the Health Information Technology for Economic and Clinical Health Act (enacted as part of the American Recovery and Reinvestment Act of 2009) ■ Government regulations and initiatives ■ Health care reform Description of products and services. The descrip- tion of services can be described as elevator speech, a term that refers to the short amount of time when one must capture the listener’s attention to provide informative, yet succinct information about a product, services, and brand. EXHIBIT 12.4. Marketing Plan Key Components ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Description of products or services Company mission statement Vision statement Description of the target market Positioning strategy Online marketing strategy Advertising and promotional strategy Sales and conversion strategy Referral and retention strategy Key performance indicators Goals Source. Adapted from Lavinsky (2013). Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 126 SECTION II. Organizational Planning and Culture Mission statement. A company mission statement is a clear and concise statement that communicates the organization’s overall goals and aspirations while functioning as the basis for strategic decision making. In other words, “Why does the company or organization exist?” For example, the mission statement for AOTA is “To advance occupational therapy practice, education, and research through standard setting and advocacy on behalf of its members, the profession, and the public” (AOTA, n.d.; “Mission Statement”). Vision statement. The vision statement is future based and relates to the company’s overall strategic plan. A well-crafted vision statement should be compelling, reflect the organization’s core values, inspire employees, and help set priorities for the future of the organization. For example, the AOTA Vision 2025 statement reads, “Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living” (AOTA, 2017, p. 1). Description of the target market. Marketing efforts that focus on meeting the specific need of a target market are the most efficient way to allocate the marketing budget, time, and resources. Knowing one’s target market is being able to describe the “ideal” clients’ behavior and their motivations for seeking out therapy services. Positioning strategy. A positioning strategy is essential for differentiating one’s products or services from the competition. The purpose of a positioning strategy is to help establish company identity and highlight how its product or services can surpass the competition. The positioning strategy should include a competitive market analysis and outline the unique selling proposition. A unique selling proposition is the real or perceived benefit that differentiates a product or service within the market of similar, competing brands. Marketing campaigns with a unique selling proposition make the product or service stand out in a market filled with similar items, thereby securing a strong position to sell to the target market. Online marketing strategy. An online marketing strat- egy is essential for a company to establish its brand, build a reputation, and to be discovered by potential customers online. Through the use of various online tools and by paying attention to key website or social media analytics, a company can increase its visibility through search engine optimization and other Internet tactics. It is imperative to gain a competitive advantage in today’s technological and consumer-driven environment where clients go online to find, review, and purchase. The primary components to a successful online marketing strategy include search engine optimization, keyword strategies, online advertising, social media marketing, reputation management, and a website conversion strategy (i.e., website content that attracts clients and leads to a sale; Martin, 2017). Advertising and promotional strategies and tactics. Consider which types of advertising, promotions, and public relations and personal selling activities are best suited for the product or services offered (see Exhibit 12.1). The advertising strategy should utilize the results of target market research to effectively communicate the brand or image and clearly inform customers of the benefits of the product or services being offered. Traditional advertising tactics include promoting a product or service through mass media such as radio, television, and direct mail and print formats such as newspapers, magazines, or other publications. Examples of online advertising campaigns include using banners on a website, performing keyword research to achieve higher Google search rankings, or using social media ads to promote the product or services. Common social media platforms for advertising are Facebook, LinkedIn, Pinterest, Twitter, and Instagram. Social media advertising is focused primarily on educating clients and providing articles of high value content that are intended to direct visitors back to the company’s website or blog. This style of social media advertising may be considered a less direct method of promotion compared to advertising. The goal of personal selling activities is developing meaningful and ongoing relationships with clients and being able to identify clients’ problems and offer the business’s products or services as a solution. Examples of public relations activities include maintaining a positive image of the company through mass media publicity, such as highlighting company achievements in press releases or being a corporate sponsor for a local charity or event. Sales and conversion strategy. A conversion strategy is the method for turning prospects into customers and making the sale. Conversion marketing is producing high-quality, engaging content that compels visitors to take action because the expertise shared fulfills their need or provides a direct solution to their problem (Lavinsky, 2013). With digital marketing, great content drives sales by attracting visitors, converting visitors into leads, converting leads into clients, and converting clients into loyal customers and evangelists for a company’s services (Marketing Matters Inbound, 2017). Referral and retention strategy. A referral strategy is a formalized set of marketing activities to gain new referrals from current clients or referral sources. Occupational therapy practitioners who provide the expected outcomes and exceptional patient experience inspire positive ratings, referrals, and repeat visits. A retention strategy focuses marketing efforts on investing in current clients or customers to buy more frequently over time. Examples of retention strategy are patient recognition for consistent attendance, a monthly newsletter, or referral incentive program. Key performance indicators. Key performance indica- tors (KPIs) are specific, numerical metrics that organizations track to measure their progress toward a defined goal in a specific timeline. Some examples of marketing KPIs include Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 12. Marketing Strategies and Analysis financial projections of sales revenue, the cost per lead, income, budget, timeline, customer lifetime value, return on investment, website traffic, conversion rates for social media, website landing page metrics, and mobile devices (Edgecomb, 2016). For example, a designated marketing budget may range anywhere from 0.5% to 10% of the gross income (Marshall, 2014). A marketing budget may go toward hiring experts skilled in website strategy, graphic design, social media, and marketing analytics. Goals. Creating goals using the SMART acronym is essen- tial in goal-setting discussions. SMART goals as related to health care marketing are ■ ■ ■ ■ ■ S = specific, significant, systematic, and synergistic M = measurable, meaningful, and motivational A = achievable, agreed-upon, action-based, and accountable R = relevant, realistic, responsible, results-oriented and rewarding T = tangible, time-based, thoughtful (Gandolf, 2017a). 127 Exchange. Exchange refers to the benefits clients receive in exchange for buying a product or service. The focus is on the benefits that clients receive in exchange for services, such as pain relief, productivity, greater independence, new skills, confidence, personal relationships, and peace of mind (Gandolf, 2017b). Evangelism. Evangelism is commonly known as word- of-mouth marketing, when a current client spreads the “good news” about the company’s product or service. Evangelism marketing has a high return on investment because clients who refer family and friends through positive referrals are essentially free. The occupational therapy manager can promote evangelism marketing by offering referral incentives. In addition, positive reviews and recommendations from current clients are powerful methods for promoting the brand and attracting future clients. Evangelism or testimonials among one’s peers, related professionals, and online influencers will also drive business toward the product and services. Implementation Implementation is the phase of executing the marketing plan by putting the marketing tactics into action, including determining who is responsible for the specific actions in the marketing plan to achieve the plan’s objectives to ultimately meet the company’s goals. Today’s most effective marketing plans include both online and offline tactics to build relationships and engage clients (Jantsch, 2011). A 21st century update to the original 4 Ps marketing mix framework is known as the 4 Es of marketing. The updated terms of the marketing mix have shifted from product to experience, from place to everyplace, from price to exchange, and from promotion to evangelism (Harnish, 2011). This evolution in terminology can be attributed in large part to the impact of the Internet, digital interactivity, and social media, which have all created a shift in the overall marketing landscape and how customers access information and make purchases. Experience. The customer experience is the product, which begins with the early stages of researching, navigating the company’s website, and scheduling an appointment to entering the office and receiving treatment. All of these touch points, from online to offline, are part of the client experience. And it is this client experience, whether positive or negative, that will result in gaining the clients’ business or potentially losing them to a competitor. Occupational therapy practitioners and managers must strive to provide an exceptional client experience, which includes excellent customer service at every interaction. Everyplace. In today’s digital age, place becomes every- place, as advertising techniques have evolved and a company’s branding can be found potentially everywhere (e.g., website, social media, ads, community events). With advances in technology and the web, potential customers can also be found everywhere rather than limited to 1 specific place or location. Monitoring Marketing plans must undergo periodic reevaluation for modifications depending on the business goals and organizational and environmental circumstances. The occupational therapy manager can use marketing questionnaires such as The Executive Guide to Marketing Effectiveness (Kotler, 2016) to assess marketing effectiveness within the organization. For online and digital marketing, tracking website metrics and social media analytics is essential for monitoring which types of advertising are the most effective for bringing in new clients. Every touch point of the client’s marketing journey should follow a process and be analyzed for effectiveness from ease of website navigation to customer service and interpersonal interactions with employees. Marketing Success and Outcome Marketing Writing SMART goals with expected marketing outcomes is essential to accurately tracking and measuring the effectiveness of the marketing plan. Outcome marketing goes beyond measuring metrics alone because it focuses on results. For example, when evaluating the marketing effectiveness of Facebook advertising, one’s focus should not be on metrics alone but rather what types of advertising, promotions, or content creation are the best lead generators and the most profitable. A clinical example of outcome marketing is when a hospital pilots a specialized evidence-based program that results in expected patient outcomes and a highly satisfying patient experience. The hospital can promote the value of this program to the target market by sharing the metrics of patient success and positive patient outcomes with a goal of attracting more patients, gaining future funding, or justifying reimbursement by payers. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 128 SECTION II. Organizational Planning and Culture EXHIBIT 12.5. Internet and Social Media Channels for Marketing ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Blogs: Regularly updated websites or webpages written in a conversational style. Facebook Live: A live broadcast of video presented on Facebook. Facebook Messenger: A mobile messaging app that can be used to communicate with the user’s friends on Facebook. Google Hangouts: A communication platform that includes text, voice, or video chat. Instagram: A social networking app for photo and video sharing from a smartphone. LinkedIn: A social network designed for career and business professionals to connect and build strategic relationships. Meetup: Real-life gatherings where members and organizers get together to connect, discuss, and practice activities related to shared interests. Online forums: Internet forums or message boards for online discussions where users can hold conversations in the forum for posted messages that may be archived. Periscope: A live video streaming platform that allows users to share video directly from their phones. Pinterest: A website that allows users to discover and save ideas in the form of images and manage them by posting them onto boards (also known as “pinning”). Reddit: A social news aggregation, web content rating, and discussion website where users submit content to the site (links, texts, posts, and images) that are voted up or down by other members. Snapchat: A mobile messaging application used to share photos, videos, texts, and drawings that will disappear from the recipient’s phone after a few seconds. Tumblr: A social blogging platform enabling users to share their own blog, interact, and follow other blogs that interest them. Twitter: An online news and social networking site that allows users to communicate in short messages called tweets to anyone who follows the user. YouTube: A video sharing website for users to watch, like, share, and comment on videos and upload their own videos. Source. Adapted from Managing the Social Media Slice of Your Marketing Plan, by S. Gandolf, 2017a. Retrieved from http://www.healthcaresuccess.com/blog/healthcare -marketing/social-media-marketing-plan.html Ideally, marketing efforts should be integrated into all aspects of the organization, from the front desk receptionist to the board of directors. Occupational therapy managers have an important role in training staff on how to provide a positive client experience as well as involving them in various marketing tasks to support the success of the company. Of equal importance is designing a systematic marketing process for interactions that will engage new prospects and build relationships with current clients who have the potential to become the company’s evangelists. Inspired by the positive outcome of their treatment and the exceptional service, these ideal clients may proactively share, refer, and recommend an organization’s services to others. Marketing Technologies and Trends Occupational therapy managers can capitalize on new technologies for marketing with the increased use of digital communication and connectivity with one another through social media and communication applications. Social media are interactive applications and tools used to share information among people via the Internet or phone. In addition, the technology for telemedicine allows occupational therapy practitioners to expand their marketing reach for potential target markets through virtual communication and teletherapy services. It is imperative for occupational therapy practitioners to create an awareness of their services, promote their brand, create engaging content, and establish their credibility through shared expertise in both offline and online platforms. Digital marketing methods are projected to lead traditional avenues of marketing. Recent surveys reveal that three-quarters of patients use search engines before making an appointment (Do, 2017). Therefore, an integrated marketing plan with a strong Internet presence will include a conversion-focused website, online advertising, reputation management, search engine optimization, and social media marketing. It is important to align the business’s goals with key business objectives. A strategic social media strategy will help the organization achieve the key performance indicators in the marketing plan (Gandolf, 2017a). To stay on top of the market, occupational therapy marketers need to expand the strategies for building connection and engagement as technology changes and evolves (Exhibit 12.5). For Additional Learning For additional learning, see Chapter 45, “Using Social Media Appropriately.” Review Questions 1. List and define the 7 Ps of marketing. 2. Define and describe the importance of an organizational assessment and an environmental assessment. Before launching a new product or service, why should an occupational therapy practitioner conduct a market analysis? 3. What are the primary components of a marketing plan? What is the purpose of a marketing plan? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 12. Marketing Strategies and Analysis PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Marketing Promotions Visit AOTA’s website (www.aota.org) and find 2 to 3 different marketing promotions that convey the value of occupational therapy. Determine the target market for these promotions or events and think about a description of the “ideal” client, including specific information to describe the client as related to demographics, geographics, psychographics, and behaviors. You can go further and give your ideal client a name and age and detailed description of who this person is and how he or she could benefit from the event or promotion. Unique Selling Proposition Consider how your business, therapy service, or product is different from that of your competitors. Keep in mind the definition of a unique selling proposition, which is the real or perceived benefit that differentiates a product or service within the market of similar, competing brands. What are ways to secure a strong position to sell to your target market? For example, if there are multiple outpatient occupational therapy clinics in your city, what are the top 3–5 reasons a potential client should choose your clinic over a different clinic? Think about ways to make your business stand out from the pediatric therapy clinics parents may be researching to provide services for their children. The first strategy is making your clinic easy to find online by maintaining your website, maximizing search engine optimization, and writing about your services in a way that offers a potential solution to a potential client’s problem. Examples of qualities that could be considered unique selling propositions that differentiate between 2 clinics offering the same types of services include customer service, ease of scheduling, therapist level of expertise, the general ambiance or vibe, and company culture from the first moment the patient walks through the door. Keep in mind that a marketing mindset should permeate all levels of the organization, from the initial phone call, throughout the course of treatment, to discharge and asking for referrals from satisfied clients (e.g., refer-a-friend program). Networking Visit AOTA’s CommunOT and Special Interest Sections to follow the latest discussions, recent blogs, and industry announcements. Consider ways you can network with other occupational therapy practitioners online (e.g., LinkedIn, Twitter). Social Media Promotion Research ways to promote a company’s brand or image on social media. What social media platform do you think a company’s clients or patients use the most? How could this knowledge be leveraged to aid in the company’s marketing 129 plan to reach and engage the ideal clients or target market? It is important to represent the company’s brand image professionally and positively. Think about topics occupational therapy practitioners could write about that offer high value content or information for their clients. It is also important to determine the best way to reach the ideal client. Avenues for reaching out to potential clients include newsletters, websites, blogs, and social media. Review Questions 1. Why is it important to identify your target market before you promote or implement a marketing campaign? 2. What are 1 or 2 web-based platforms or social media channels that AOTA could use to promote the profession? 3. After comparing 2 companies or websites that offer the same type of occupational therapy services, why is a unique selling proposition important? What traits do the companies have in common? What are the qualities or services that differentiate them from their competition? Which would you choose and why? SUMMARY The health care environment is constantly changing. Therefore, it is imperative that occupational therapy providers, as individuals and as part of the greater profession, serve as advocates in promoting the distinct value of occupational therapy through marketing and advocacy efforts. It is important for occupational therapy practitioners, managers, and leaders to understand how an effective marketing plan influences the overall success and financial stability of the organization. Equipped with an understanding of marketing fundamentals, marketing research, and a structured marketing plan, occupational therapy practitioners and managers will be better equipped to anticipate their clients’ needs and offer solutions. The original marketing mix concepts of the 4 Ps (product, price, place, and promotion) are merging with the modern-day framework of the 4 Es (experience, everyplace, exchange, and evangelism; Edgecomb, 2013). This evolution in marketing approach is directly related to the rise in technology because an exponentially increasing number of consumers are relying heavily on the Internet, mobile devices, and social media to research their health care options. The best way to reach these target markets is through an online and digital marketing tactic that focuses on engaging consumers with valuable information, offering a unique solution to a problem, and ultimately providing an exceptional client experience (online and offline) that is enough to warrant the client evangelizing to others about a company’s services. The future marketing success of occupational therapy practice must keep pace with technology to meet the needs of today’s empowered and informed health care consumer. Occupational therapy practitioners have the ability to positively affect and influence society while leaving a digital and societal footprint. Today’s occupational therapy practitioners, Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 130 SECTION II. Organizational Planning and Culture CASE EXAMPLE 12.1. Conducting an Organizational Assessment Emily works in the rehabilitation hospital’s inpatient unit treating patients with neurological deficits, such as traumatic brain injury and stroke. She completes an organizational assessment with a SWOT (strengths, weaknesses, opportunities, threats) analysis to determine whether the unit has the resources, budget, staffing, and potential opportunities to support a new patient program. This IADL training program will be located on the unit floor and focuses on teaching independent living skills and home management tasks prior to discharge home (e.g., simple meal preparation, managing household chores, money management). Emily also conducts a market analysis for the current patients who would be appropriate for this group program. Her goal is to determine the best day of the week, time, frequency, and level of interest. The information will be gathered from this target market using a survey and talking to patients and their families about which specific daily tasks and roles are the most difficult to perform. She collects her survey results and determines the dates, times, description of the group program, and potential outcomes for its participants. She uses this information to create a flyer to promote the new IADL group to prospective patients and referring physicians. Review Questions 1. 2. 3. What is the acronym used to summarize the components of an organizational assessment? What are these components? Give some examples of how Emily analyzed her market and conducted an environmental assessment to address the needs of the patients in an IADL group. What are the methods she uses to obtain this information? As her manager, what are some examples of how you could promote this group program? Which types of social media do you think would be the most appropriate for Emily’s target market and potential referral sources? managers, and leaders must understand how marketing’s ever-increasing potential is essential to propel the profession forward to fulfill occupational therapy’s brand promise of “Living Life to Its Fullest” for as many people as possible. ❖ LEARNING ACTIVITIES 1. Visit AOTA’s website and identify 3 social media channels that are being used to promote valuable content, news, or upcoming events. Write examples of how you would promote the content using a specific channel of social media. 2. Find 2 websites that offer the same type of occupational therapy services (e.g., hospital, outpatient pediatric clinic, hand therapy, mental health, geriatrics SNF, industrial rehabilitation). Perform a competitive market analysis by identifying the unique selling proposition of each. ACOTE STANDARDS This chapter addresses the following ACOTE Standards: • • • • B.4.29. Reimbursement Systems and Documentation B.5.3. Business Aspects of Practice B.5.6. Market the Delivery of Services B.5.7. Quality Management and Improvement. REFERENCES Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7912410005. https://doi .org/10.5014/ajot.2018.72S17 American Marketing Association. (2013, July). Definition of marketing. Retrieved from https://www.ama.org/AboutAMA/Pages /Definition-of-Marketing.aspx American Occupational Therapy Association. (n.d.). Mission statement. Retrieved from https://www.aota.org/AboutAOTA.aspx American Occupational Therapy Association. (2017). Vision 2025. American Journal of Occupational Therapy, 71, 7103420010. https://doi.org/10.5014/ajot.2017.713002 Bitner, M. J., & Brooms, H. (1981). Marketing strategies and organization: Structure for service firms. In J. H. Donnelly & W. R. George (Eds.), Marketing of services (pp. 47–52). Chicago: American Marketing Association. Bureau of Labor Statistics. (2017). Occupational outlook handbook occupational therapists. Retrieved from https://www.bls .gov/ooh/healthcare/occupational-therapists.htm Do, P. (2017, September 15). 5 ways to clobber the competition with healthcare marketing. Retrieved from http://www.healthcare success.com/blog/healthcare-marketing/clobber-competition -healthcare-marketing.html Edgecomb, C. (2013, August 28). The 4 E’s of inbound marketing. Retrieved from https://www.impactbnd.com/blog/the-4-es-of -inbound-marketing Edgecomb, C. (2016, February 16). The 10 marketing KPIs you should be tracking. Retrieved from https://www.impactbnd.com /the-10-marketing-kpis-you-should-be-tracking Entrepreneur Encyclopedia. (n.d.). Target market. Retrieved from https://www.entrepreneur.com/encyclopedia/target-market Gandolf, S. (2017a, September 18). Managing the social media slice of your marketing plan. Retrieved from http://www.healthcaresuccess .com/blog/healthcare-marketing/social-media-marketing-plan .html Gandolf, S. (2017b, April 20). What is a healthcare marketing plan? Retrieved from http://www.healthcaresuccess.com/blog/healthcare-marketing/what-is-marketing-plan.html Hanlon, A. (2018, May 31). How to use the 7Ps marketing mix. Retrieved from https://www.smartinsights.com/marketing-planning /marketing-models/how-to-use-the-7ps-marketing-mix/ Harnish, V. (2011, September 21). Improving marketing: Five techniques. Retrieved from https://gazelles.com/article/improving -marketing-five-techniques Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, 42 USC sec 139w-4(0)(2) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 12. Marketing Strategies and Analysis Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104–191 Jantsch, J. (2011). Duct tape marketing. Nashville, TN: Thomas Nelson. Kotler, P. (2000). Marketing management: Millennium edition (10th ed.). Upper Saddle River, NJ: Pearson. Kotler, P. (2003). Marketing insights from A to Z: 80 concepts every manager needs to know. Hoboken, NJ: Wiley. Kotler, P. (2016). The executive guide to marketing effectiveness. Marketing Journal. Retrieved from http://www.marketingjournal.org /the-executive-guide-to-marketing-effectiveness-philip-kotler/ Kotler, P., & Armstrong, G. (2010) Principles of marketing (13th [Global] ed.). Boston: Pearson Education. Kotler Marketing Group. (n.d.). What is marketing? Retrieved from http://www.kotlermarketing.com/phil_questions.shtml #answer3 131 Lavinsky, D. (2013, September 30). Marketing plan template: Exactly what to include. Forbes. Retrieved from https://www.forbes.com /sites/davelavinsky/2013/09/30/marketing-plan-template-exactly -what-to-include/#315a57ed3503 Marketing Matters Inbound. (2017). The 4E’s of inbound conversion marketing content that converts. Retrieved from https://marketing ­mattersinbound.com/inbound-conversion-marketing/ Marketing Teacher. (n.d.). Marketing essentials. Retrieved from http://www.marketingteacher.com/lesson-store/#essentials Marshall, M. (2014). Putting together the entrepreneurial puzzle: The ten pieces every business needs to succeed. Charleston, SC: Veritas Vincit Press. Martin, G. (2017). The essential social media marketing handbook. Wayne, NJ: Career Press. Newberry, C. (2018, July 10). What is a social media influencer? Retrieved from https://blog.hootsuite.com/influencer-marketing/#whatis Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Building Capacity 13 Susan Touchinsky, OTR/L, SCDCM, CDRS LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Discuss the application of capacity building in the current health care system, ■ Recognize and learn steps to developing capacity, and ■ Apply concepts of capacity building to develop specific clinical programs within occupational therapy departments. KEY TERMS AND CONCEPTS • • • • Bottom-up approach Capacities Capacity building Capacity development • • • • Community approach Infrastructure Needs assessment Partnership approach OVERVIEW T he current health care environment continues to demand that occupational therapy practitioners and managers do more with less, increase efficiency, and ensure positive revenue. These pressures can be a great demand on a manager and department and may result in management that leads to restraint to reduce cost and inefficiencies, minimalism, and staff dissatisfaction. Capacity building involves a range of methods and processes to develop, improve, and maintain skills needed to do a job. It often includes a systematic approach and reflects a long-term, continual process. By applying capacity building, managers can ensure a thorough process for program development that focuses on efficiency and sustainable outcomes. It also reflects important elements of capacities and reciprocal relationships (Lorenzo & Joubert, 2011). These elements will be vital for job satisfaction and commitment to the process. ESSENTIAL CONSIDERATIONS Capacity building is the development of systems, processes, and strategies aimed at developing sustainable outcomes for improving health practices. Education, research, and • Reciprocal relationships • Stakeholders • Top-down approach methodology are used to expand services and meet a greater need of the community. It is most commonly used in developing communities; however, it is appropriately applied to the ongoing development of systems for health care and, specifically, occupational therapy (United Nations Development Programme [UNDP], 2009). The term capacity building lends itself well to the idea of program development for occupational therapy as it reflects the idea of establishing and implementing sustainable systems with built-in strategies for continuous quality improvement and revisions. Not unlike the process of occupational therapy, the process of capacity involves ■ ■ ■ ■ ■ Identifying stakeholders (i.e., caregivers), Assessing needs (i.e., evaluation), Developing reciprocal relationships (i.e., building rapport), Developing an infrastructure (i.e., plan of care), and Continually reassessing and revising (i.e., altering interventions and revising new goals) to help achieve improved quality systems (i.e., reach goals of operating at full capacity). Because the process of capacity building mimics occupational therapy, it is a process that many occupational therapy managers have already naturally developed. These steps Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.013 133 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Building Capacity 13 Susan Touchinsky, OTR/L, SCDCM, CDRS LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Discuss the application of capacity building in the current health care system, ■ Recognize and learn steps to developing capacity, and ■ Apply concepts of capacity building to develop specific clinical programs within occupational therapy departments. KEY TERMS AND CONCEPTS • • • • Bottom-up approach Capacities Capacity building Capacity development • • • • Community approach Infrastructure Needs assessment Partnership approach OVERVIEW T he current health care environment continues to demand that occupational therapy practitioners and managers do more with less, increase efficiency, and ensure positive revenue. These pressures can be a great demand on a manager and department and may result in management that leads to restraint to reduce cost and inefficiencies, minimalism, and staff dissatisfaction. Capacity building involves a range of methods and processes to develop, improve, and maintain skills needed to do a job. It often includes a systematic approach and reflects a long-term, continual process. By applying capacity building, managers can ensure a thorough process for program development that focuses on efficiency and sustainable outcomes. It also reflects important elements of capacities and reciprocal relationships (Lorenzo & Joubert, 2011). These elements will be vital for job satisfaction and commitment to the process. ESSENTIAL CONSIDERATIONS Capacity building is the development of systems, processes, and strategies aimed at developing sustainable outcomes for improving health practices. Education, research, and • Reciprocal relationships • Stakeholders • Top-down approach methodology are used to expand services and meet a greater need of the community. It is most commonly used in developing communities; however, it is appropriately applied to the ongoing development of systems for health care and, specifically, occupational therapy (United Nations Development Programme [UNDP], 2009). The term capacity building lends itself well to the idea of program development for occupational therapy as it reflects the idea of establishing and implementing sustainable systems with built-in strategies for continuous quality improvement and revisions. Not unlike the process of occupational therapy, the process of capacity involves ■ ■ ■ ■ ■ Identifying stakeholders (i.e., caregivers), Assessing needs (i.e., evaluation), Developing reciprocal relationships (i.e., building rapport), Developing an infrastructure (i.e., plan of care), and Continually reassessing and revising (i.e., altering interventions and revising new goals) to help achieve improved quality systems (i.e., reach goals of operating at full capacity). Because the process of capacity building mimics occupational therapy, it is a process that many occupational therapy managers have already naturally developed. These steps Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.013 133 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 134 SECTION II. Organizational Planning and Culture are discussed further in the section “Steps for Developing Capacity.” Capacity building goes beyond basic quality improvement. In a health care system with constant flux, building capacity helps ensure continued growth and change to meet the evolving needs of the health care environment by ensuring that the organization and its systems remain relevant. Capacity and Capacity Development Capacities include both tangible items such as equipment, revenue, and products, as well as personal skills such as the skill set of the individual occupational therapy practitioner, leadership skills of the department head, and support skills of the large personnel structure. Board and specialty certifications are examples of personal skill capacities. During capacity building, the development of personal capacities remains front and center to ensure that skills are effective and relevant (Eade, 1997). The implementation of the capacity-building process, known as capacity development, focuses on development of resources, reciprocal relationships with key groups and individuals, infrastructure to support growth, and ongoing assessment. Capacity development engages review and revision that ensures quality, growth, development, efficiency, and ultimately success. This is a continual process rather than a project with a start and a finish. This process results in improved quality and helps foster a more integrated, sustainable system (Corbei-Smith et al., 2015). Reciprocal Relationships Reciprocal relationships are relationships in which both participants benefit from the relationship. The development of reciprocal relationships may be with key groups or individuals. Groups may include other departments within the same system or key supporting groups external to the system; individuals may include internal occupational therapy practitioners. Developing reciprocal relationships is key during capacity building for developing a sustainable process, culture, and supportive infrastructure (Lorenzo & Joubert, 2011). Consider the reciprocal relationships between a rehabilitation facility manager and an occupational therapy practitioner working to start a hand clinic. A reciprocal relationship might include an agreement that the company pay for advanced training and board certification in hand therapy for the practitioner, who in return will agree to specific time commitments, productivity measures, and patient outcomes. The reciprocal relationship reinforces capacity development of the hand clinic and motivates each party (Lorenzo & Joubert, 2011). Reciprocity between 2 or more individuals or groups is key for continued growth and sustainable development. For example, a program that has levels of personnel engaged, with small overlaps of roles, will continue to do well even if a practitioner goes out on family medical leave or leaves the program. Programs built by a single practitioner, without reciprocal relationships to ensure continuity, fail when that person (or capacity) leaves, which results in a gap that will either require reworking a plan to restart the program or program termination. Such situations can be avoided if the time is taken to build relationships and capacity among several occupational therapy practitioners. In the previous example, developing a second practitioner’s skills in hand therapy would ensure a sustainable capacity. Then, the second practitioner would also be developing reciprocal relationships that would allow them to continue easily with the program, should the first practitioner leave (Lorenzo & Joubert, 2011). In another example, consider a rehabilitation hospital that is starting an outpatient driving rehabilitation program. A single occupational therapy practitioner is identified and trained to become a specialist. Limited resources are allocated to support reciprocal relationships with the other practitioners and referral sources, resulting in limited interest. Program development is limited to the specialist, and capacity development is limited. When the specialist is gone on medical leave and no other occupational therapy practitioners are available in this area of practice (and no sustainable referral relationships have been developed), the program is discontinued. Situations like this may be avoided if the time is taken to develop interest in the program, build numerous relationships, and continue with capacity building among several practitioners. Infrastructure Infrastructure is the network and systems used to support capacity development. Development of infrastructure is needed to support growth and may include structures such as a policy and procedures manual, mission or vision statements, care delivery models, best practices, documentation and communication systems, and program guidelines. Infrastructure is valuable in supporting the process for development of capacities and reciprocal relationships. In general terms, the infrastructure supports daily operations as well as global goals. Infrastructure allows the program to function on a day-to-day basis without constant oversight because there are systems in place and the staff simply follow the rules and procedures (Corbei-Smith et al., 2015). The value of a strong infrastructure, especially a mission or vision statement, should not be minimized. It is a critical step for capacity development and is needed to foster independence, support integration of systems, strengthen program outcomes, and enhance the development of human potential (UNDP, 2009). Steps for Developing Capacity According to the UNDP (2009), capacity building includes 5 steps: 1. 2. 3. 4. 5. Identification and engagement of stakeholders, Identification of assets and needs (needs assessment), Identification of approach, Implementation of plan, and Ongoing evaluation of the program. This section discusses each step as it relates to occupational therapy practice. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 13. Building Capacity Identification and engagement of stakeholders Capacity building begins with identification and then engagement of key stakeholders. Stakeholders are the individuals or groups that have a financial or personal investment in the program or process and may be used to leverage support or develop infrastructure, capacities skills, and reciprocal relationships. Stakeholders for occupational therapy program development may include the hospital chief financial officer, outpatient manager, director of social services, marketing director, risk management and maintenance personnel, and other therapy team members. It is important to start by identifying those individuals and groups who will affect capacity development. Stakeholders may be supportive, indifferent, or opposed. These relationships should be considered carefully, and stakeholders should be engaged in reciprocal relationships (a win–win situation). This is key for developing a sustainable relationship and ensuring investment in the project/process. For example, consider a program’s mission and values and how stakeholders embrace these values and the extent to which they align with the goal of capacity building. Deepen the commitment and involvement of the stakeholder by engaging them in the decision-making and implementation processes. This will foster a sense of responsibility in the process and ownership. An invested stakeholder will work to support the goals of capacity building, rather than being an obstacle. Think of capacity building as a stream of water with momentum. An engaged stakeholder becomes the leaf floating on the stream, while a disengaged or unengaged stakeholder may be a rock or even a dam. Even stakeholders who are simply opposed and uninvolved can still interrupt or interfere with program efforts. Identification of assets and needs (needs assessment) A needs assessment is performed to identify and assess needs and assets, including knowledge, interests, abilities, and skills of capacities; state of current infrastructure; current culture; reciprocal relationships; and opportunities for changes to improve process. During the needs assessment process, the current state of a program is reviewed thoroughly and objectively to gather information about the following areas: ■ Infrastructure. Is there an existing structure to support sustainable and efficient program growth, such as policies and procedures or a mission? A stable infrastructure will provide the rules needed to guide the program in daily operations and establishes safeguards to ensure success and quality. ■ Culture. How will the culture affect acceptance of the process or program? Understanding the prior history of the culture and current state of moods, attitudes, and willingness to change will be imperative for knowing how to move forward with program development. ■ Needs and resources. What needs exist and what capacities or resources are already in place? Understanding what is needed will help identify current gaps in occupational therapy practice. 135 Qualitative information is gathered through focus groups, interviews with key informants, surveys, and department meetings. Use the needs assessment process as an opportunity to identify strengths as well as opportunities for improvement. After information is gathered, the needs are analyzed to identify priorities, gaps, and next steps. To move forward, there must be a clear understanding of past history and culture: identify what works, what has not worked (and why), and the challenges encountered. Understanding this history is necessary to build a foundation and move forward. It is also essential to ensure that efforts are not spent on repeating or recreating failed approaches. This process is about efficiency and sustainability. Use the needs assessment to identify both what is needed and what is already established that may be used (Organisation for Economic Co-operation and Development, 2006). Identification of approach To build capacity in health care, Crisp et al. (2000) described 4 approaches: (1) bottom-up, (2) top-down, (3) partnership, and (4) community. Typically, more than 1 approach is used when developing capacity, and in many situations all 4 are integrated to develop a sustainable approach. Bottom-up approach. A bottom-up approach to build- ing organizational capacity focuses on developing capacities in people by working on the development of performance skills of the employee or expert. This approach looks specifically at the clinical skills of the occupational therapy practitioner, identifies potential areas for growth and expansion of skills, and then provides opportunities to expand the skills or capacities of practitioners. The idea is that by focusing on personnel development, less reliance is needed on external consultants and resources. Individuals can gain technical expertise and then train one another (i.e., train-the-trainer model; Eade, 1997). For example, an employer might send an occupational therapy practitioner to a specialized training course, and then this practitioner could, in turn, educate other clinicians in the program. A bottom-up approach can work well if many clinicians need to be trained and it is a skill that can be taught easily by trainers. A bottom-up approach is also beneficial when capacity development focuses on change at the individual level. This approach reinforces the reliance on the individual skill set to integrate and then sustain change. Top-down approach. A top-down approach focuses on developing infrastructure to support program development. Attention is paid to policies, procedures, and program guidelines that support the goal of growth and development. The infrastructure outlines the rules that guide the program in daily operation and establishes safeguards to ensure success and quality. A top-down organization of a community-based, outpatient occupational therapy program may include policy and procedures for providing mobile treatment, emergency preparedness, or storage of medical records. This method is used more commonly to change at the facility level versus the individual level. This change is helpful for development of infrastructure. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 136 SECTION II. Organizational Planning and Culture Partnership. A partnership approach reinforces the value of reciprocal relationships and focuses on establishing mutually beneficial partnerships among groups of people and organizations that may not normally interact. This approach emphasizes building capacity by building relationships and communications among different groups to help reach a goal. Such relationship building could mean fostering relationships between departments within an institution that do not normally connect, such as risk management and maintenance and therapy to establish an occupational therapy driving rehabilitation program. More broadly, such relationship building could include developing relationships with other organizations, such as the state licensing administration or state medical advisory board (Lorenzo & Joubert, 2011). This capacity development approach has proven valuable for establishing and maintaining connections between groups and stakeholders. Without use of this approach, capacity development tends to “fizzle out” and be less effective. Relationships with invested stakeholders are needed to build sustainability. Ongoing evaluation of the program Community approach. A community approach is used ■ more commonly for community-based capacity development. It tends to focus on the most disenfranchised communities and works to engage community members by moving them from a state of disengagement to engagement. This approach focuses on the capacities of individual community members to develop reciprocity and an integrated culture. The community approach is needed when developing capacity in a culture where change is needed to improve the situation. It integrates elements of the partnership and the bottom-up approach to identify key community members who have an interest in effecting change (Crisp et al., 2000). A risk to this approach is the trend for community members with newly acquired or strengthened skills to leave the community for alternate employment opportunities. For example, a community approach may be engaged to help rebuild the culture of an occupational therapy program after sustaining significant loss from company layoffs or other events that have left a negative culture, such as negative program reviews or numerous customer service complaints. Implementation of the plan After stakeholders have been identified and engaged, needs have been assessed and prioritized, and a plan of approach has been developed, the plan can be implemented. Implementation should occur at the individual, institutional, and global levels. Strategies and the pace for implementation will vary according to stakeholders, development of reciprocal relationships, and capacities. The implementation will also be affected by the current culture’s readiness to change. Approach implementation as an ongoing and continual process that needs regular evaluation. As such, it is important to have measurable achievements, positive reinforcements, and goals to use for progress evaluation. The evaluation and ongoing review are applied to the capacity development process to determine effectiveness and efficiency for developing capacity and program sustainability against established measures. This part of the process promotes accountability and commitment. Evaluation should include all parts of the system—from infrastructure, to stakeholders and reciprocal relationships, to capacities and opportunities for growth. The evaluation process should include a review of the following areas: ■ Infrastructure. Ensure that guidelines and policies are ■ ■ present to support sustainability, review processes for efficiency of flow, and evaluate the infrastructure’s ability to engage capacities and promote sustainability. Stakeholders. Evaluate buy-in, engagement, the benefits of the relationship, and opportunities for improvement or need for dissolution. Capacities. Evaluate the scope of skills, availability of resources, and method for continuing development and integration. Opportunities for growth. Identify successes and areas that need further development; identify opportunities for change and develop approaches to continue capacity building. Review Questions 1. How are the steps for developing capacity similar to the therapeutic process used by occupational therapy practitioners? 2. What are the disadvantages of developing capacity without identifying stakeholders or completing a needs assessment? 3. Thinking about your own practice or vision of how you would like your practice to look like in the future, identify examples of when each of the 4 approaches may be used for your own capacity building. PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Table 13.1 lists the steps for capacity building and highlights focus areas and guiding questions. This table may be helpful when considering capacity development and during the process to ensure that all steps are being implemented. The following list provides a summary of general tips and practical experience for capacity building. ■ The needs assessment process is a great opportunity to ensure a complete understanding of infrastructure, culture, resources, and opportunities for change. It is also a great opportunity to incorporate discovery of information to identify the program’s vision. Development of a vision or mission statement is essential for successful program development. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 13. Building Capacity 137 TABLE 13.1. Steps for Developing Capacity STEPS FOR DEVELOPING CAPACITY AREAS OF FOCUS QUESTIONS TO GUIDE STEPS FOR DEVELOPING CAPACITY WITHIN AN OCCUPATIONAL THERAPY DEPARTMENT Identify stakeholders ■ Identification of key individuals ■ Determination of thoughts, beliefs, and motivations ■ Review of current need to develop reciprocal relationships ■ Method for engagement in decisionmaking process ■ Method for invested for support, growth, outcome, and program sustainability ■ Foster partnership and ownership ■ Who are the key individuals or groups? ■ What are the thoughts, beliefs, and motivations of these stakeholders? ■ What relationships exist and how can these be strengthened? What relationships need development? ■ How can stakeholders be leveraged to support program development and promote investment in development? What are the primary and secondary gains? ■ How can the strengths of the stakeholder be leveraged to make decisions and improve the process? Identify assets and needs (complete a needs assessment) Identification and review of: ■ Needs ■ Gaps in practice ■ Capacities ■ Infrastructure ■ Culture trends ■ Reciprocal relationships ■ Assess readiness to change ■ Level of buy-in or engagement ■ Prioritize needs and actions ■ What are the current medical and occupational therapy needs of the health care environment? ■ What needs are being met and what resources exist? ■ What needs are not being addressed? What are the gaps in practice? ■ What are the current capacities of the department and individual practitioners? Does a needed skill exist or who presents with potential for development? ■ What training will be needed? ■ What reciprocal relationships, guidelines, and/or policy and procedures exist to support program development? ■ What is the current culture of the team? What is the readiness to change? ■ What areas should be prioritized? ■ What is the primary type of change needed: individual capacities, infrastructure, relationship development, or community level? Identify plan of approach ■ ■ ■ ■ Bottom-up Top-down Partnership Community organizational Bottom-up approach ■ What occupational therapy training will be needed to reach the goal? ■ What will be the method for initial and continued training? ■ What are the considerations for investment of training time and resources? Is formal employee commitment needed? ■ What opportunities exist for mentorship of newly developed skills? Top-down approach ■ What policies, specialty job descriptions, practice acts, and regulatory guidelines exist or need to be developed? ■ What equipment will be needed? Partnerships ■ What internal or external relationships exist and could be strengthened? What new relationships could be developed? ■ What are the key organizations that support your program development? ■ What are opportunities for building reciprocal relationships? Community development ■ How can lead capacities be identified and developed to lead change? ■ How can these capacities be motivated to remain in the community? Implementation ■ Individual, institution, global levels ■ Varying pace and timing ■ Who are the key people? ■ What are the goals and key indicators to measure success? Evaluation and ongoing evaluation of program ■ Promotes accountability ■ What do the key indicators show? ■ Measures performance-based measures ■ How do the following categories support the goal: infrastructure, stakeholders, reciprocal relationships, and current capacities? ■ What are the opportunities for growth? ■ Revise and continue Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 138 SECTION II. Organizational Planning and Culture ■ The use of more than 1 approach may be needed to achieve Review Questions ■ 1. Is the process of developing capacity linear or ongoing? Why or why not? 2. Can capacity building be effective and sustainable if stakeholders, capacities, and infrastructure are developed only within the occupational therapy department? 3. What step of capacity development might be most challenging? ■ ■ goals, but it is important to identify and define which approach or delivery model will be used to guide actions and practice. This is needed to ensure that all participants have a clear understanding of the approach, which will result in better alignment of key participants and more cohesive efforts. Do not underestimate the value of the stakeholders and building of reciprocal relationships. These relationships often determine the sustainability or long-term success of capacity building. Focus on both internal and external relationships to ensure engagement of stakeholders on all levels. With occupational therapy, most capacity building occurs with clinical treatment programs. This means that capacity may be dependent on individual occupational therapy practitioners. It will be important to layer the development of skills or capacities to ensure that the program does not stall or fail if a practitioner leaves the program. Taking the time up front to identify and engage stakeholders and complete a needs assessment will ensure efficiency sustainability. Case Example 13.1 describes capacity building in the context of driving and community mobility. CASE EXAMPLE 13.1. SUMMARY The process of capacity building lends itself well to the needs of an occupational therapy manager looking to develop and implement sustainable programs. The process itself (of needs assessment, reciprocal relationships, development of infrastructure, implementation, and evaluation) reflects our foundational practices within occupational therapy, making capacity building a natural fit with the profession. Many occupational therapy managers have already naturally developed the process and can learn to apply our capacity more thoroughly. Each step is integral for developing a sustainable approach and to achieve positive quality outcome and program development. ❖ Building Capacity to Improve Driving and Community Mobility Services An occupational therapy department at an inpatient rehabilitation hospital has identified the need to improve services that address driving and community mobility. Recently a patient was discharged from the hospital after recovering from a stroke. The patient walked out to his car in the parking and attempted to drive home, only to cause a 4-vehicle crash at the exit light of the hospital. The crash has resulted in increased concerns from the physicians, hospital, and community at large. Identify Stakeholders Through targeted interviews and discussions, the following individuals and groups have been identified as stakeholders with the following assets (Dickerson et al., 2011): ■ Occupational therapy department ■ Therapy providers who will evaluate, assess, and intervene to assess performance skills needed for driving and community mobility; identify areas of concern; communicate to other team members; and then refer for additional services as needed. ■ Invested to improve quality of care provided to patients and assist patients with meeting goals for driving and community mobility. ■ Director of Physical Medicine and Rehabilitation Department (PM&R) ■ Direct organizational support to practitioners. ■ Assist with development of program guidelines and policy and procedures to support needed infrastructure. ■ Provide direct oversight, assistance for interventions and billing, and support for development of clinicians’ capacities; develop reciprocal relationships with other stakeholders; support communication from occupational therapy practitioners to the referring physician. ■ Motivated to support clinical team, physician groups, and hospital. ■ PM&R physicians ■ Lead member of the medical team who will receive objective information from the therapy team to make recommendations related to client driving. ■ Position reinforced by state licensing agency that requests reports concerning medication conditions by physician. ■ Physician buy-in related to well-being of patient, practice, and hospital, as well as ethical obligations as outlined by the state licensing agency. ■ Social services department ■ Representative to support patient goals and discharge disposition. ■ Motivated to provide patient support and transportation options that align with recommendations from a physician and occupational therapy practitioners. ■ Hospital administration ■ Provide overview operation structure and support. ■ Motivated to reduce risk management, to generate revenue, and to improve facility reputation. (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 13. Building Capacity CASE EXAMPLE 13.1. ■ 139 Building Capacity to Improve Driving and Community Mobility Services (Cont.) Hospital risk management department Provide support for the development of policies and procedures that reflect risk management as well as meet the requirements of the state licensing agency. ■ Motivated to reduce risk and liability of hospital and to ensure that physicians and clinicians are operating within role as providers. State licensing agency ■ External stakeholder may have little investment in program development but will be key for developing a positive relationship with physicians who report concerns. ■ Motivated to provide driver’s license to drivers who demonstrate skills for operating a motor vehicle and to protect state residents by ensuring that motorists have the skill set need to operate a motor vehicle. Hospital community, local state police, and emergency responders ■ Concerns from the surrounding community for the safety of the residents in the immediate vicinity of the hospital. ■ Motivated to reduce crash risk and increase awareness of safety for all drivers. ■ Many are motivated to work for an employer who addresses community concerns for safety and represents values that reflect community goals. ■ ■ ■ Identify/Assess Needs and Assets Once the stakeholders have been identified, a needs assessment is completed to identify current capacities (knowledge, interests, abilities, and skills of clinicians), state of current infrastructure, current culture, reciprocal relationships, needs, and opportunity for changes to improve the process. ■ ■ ■ ■ Capacities: Current capacities include an occupational therapy team of 4 OTs and 2 OTAs; neighboring driving rehabilitation program at a hospital 75 minutes away; state that supports physician medical reporting; engaged physicians looking for support to better address driving concerns with patients; motivated stakeholders. Infrastructure: Stable therapy department with standard program guidelines to support therapy intervention; national support and guidance with the American Occupational Therapy Association (2016) statement on driving and community mobility; will need development for communication of recommendations to physician and client. Culture: Clinicians are motivated to ensure that clients have discharge plans designed to keep them safe. Two of the practitioners are interested in addressing driving and community mobility. They report that they do their best to address this area of practice before the client is quickly discharged, but at times they are frustrated with the fast turnover of patients, and they have concerns about their role in addressing this area of practice. Specifically, the practitioners report that they are unclear about what they should evaluate and what they, as generalists in practice, may recommend versus an occupational therapy driver rehabilitation specialist (DRS). Overall, these clinicians are interested in change and eager to learn more. The program manager is also very motivated. She recently had to discuss driving with a member of her own family and believes that something more needs to be done. She has concerns about practice guidelines for supporting driving and community mobility. Needs: Training for occupational therapy practitioners’ role with driving and community mobility; program policy and procedures to support program and billing; identification of current best practices and guiding practice statements; method for communicating plans and changes; developing a better understanding of state licensing reporting laws and consideration; developing understanding for role of state driver’s licensing medical advisory board (Dickerson & Schold Davis, 2014; Lane et al., 2014). Identify Approach While many stakeholders will be involved in the success of building the capacity of the occupational therapy department to expand its services for driving and community mobility, the skill set of the occupational therapy practitioners will be critical (Betz et al., 2014). Therefore, a bottom-up capacity development approach will be the primary approach. This approach will start with developing the capacities of the 2 lead OTs through enrollment in courses, including Driving and Community Mobility: Occupational Therapy Strategies Across the Lifespan (McGuire & Schold Davis, 2012) and other education. Practitioners will then use their developed capacities to work collaboratively with the program manager and hospital administration to develop methods for documentation and billing, communication channels to internal stakeholders such as physicians and social services, and needed program guidelines or policies. A top-down approach will be used to supplement the focused bottom-up work by developing an overarching vision and mission. OT-DRIVE (Schold Davis & Dickerson, 2017) and AOTA’s (2016) Driving and Community Mobility statement will be used as guiding documents to educate stakeholders and ensure the occupational therapy team is addressing needs within their scope of practice and then referring to the occupational therapy DRSs as needed. A partnerships approach will also be important for the many varying relationships needed between stakeholders to develop the capacity plan, implement, evaluate, and ensure sustainability. Relationships between relevant parties (e.g., among the occupational therapy practitioners, among the practitioners and program manager, the practitioners and state Medical Advisory Board to the Department of Motor Vehicles [DMV] program manager and hospital administration, program manager, practitioners, and physicians) will all be important to develop and evaluate for effectives, efficiency, and sustainability. Implementation Implementation will occur at varying levels from practitioner, to department, to hospital. Initial plans for implementation will include a plan for education of the practitioner, followed by development of infrastructure focused on state practice acts and guiding practice documents and, ultimately, provision of care. Implementation will require a point person to prioritize tasks, evaluate, and modify the approach. Care will be taken to engage stakeholders and to encourage readiness for change. This will be an ongoing and continual process that needs regular evaluation and will use measurable achievements, positive reinforcements, and goals to evaluate progress. (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 140 SECTION II. Organizational Planning and Culture CASE EXAMPLE 13.1. Building Capacity to Improve Driving and Community Mobility Services (Cont.) Evaluation Plans have been made for adjusting evaluation of the capacity building at varying levels. For example, to support and ensure individual capacity development, weekly evaluation of the practitioners by the program manager will be used to sustain growth. Weekly evaluation may also be used to ensure that effective relationships have been developed between therapy and the physicians and social services. Monthly meetings between the therapy departments and hospital administration will be used to evaluate program success. Program success will be measured by referrals to occupational therapy DRS, customer satisfaction, physician satisfaction, and number of clients receiving occupational therapy driving and community mobility interventions. Evaluation of the program’s ability to protect community interests will be evaluated annually. Review Questions 1. 2. 3. In the case study above, identify the pros and cons of having 2 occupational therapy practitioners complete the training as compared with 1 practitioner who completes the training and then trains the rest of the occupational therapy team. Regarding stakeholders, what strategies might be implemented to develop engagement with the risk management department? Physicians? Social services department? What are the primary and secondary gains made from developing reciprocal relationships with outside stakeholders, such as the DMV? ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ B.5.1. Factors, Policy Issues, and Social Systems ■ B. 5.7. Quality Management and Improvement. REFERENCES Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7912410005. https://doi .org/10.5014/ajot.2018.72S17 American Occupational Therapy Association. (2016). Driving and community mobility. American Journal of Occupational Therapy, 70, 7012410050. https://doi.org/10.5014/ajot.2016.706S04 Betz, M. E., Dickerson, A., Coolman, T., Schold Davis, E., Jones, J., & Schwartz, R. (2014). Driving rehabilitation programs for older drivers in the United States. Occupational Therapy in Health Care, 28, 306–317. https://doi.org/10.3109/07380577.2014.908336 Corbei-Smith, G., Bryant, A. R., Walker, D. J., Bluementhal, C., Council, B., Courtney, D., & Adimora, A. (2015). Building capacity in community-based participatory research partnerships through a focus on process and multiculturalism. Progress in Community Health Partnerships: Research, Education, and Action, 9(2), 261–273. https://doi.org/10.1353/cpr.2015.0038 Crisp, B. R., Swerissen, H., & Duckett, S. J. (2000). Four approaches to capacity building in health: Consequences for measurement and accountability. Health Promotion International, 15(2), 99–107. https://doi.org/10.1093/heapro/15.2.99 Dickerson, A. E., & Schold Davis, E. (2014). Driving experts address expanding access through pathways to older driver rehabilitation services: Expert meeting results and implications. Occupational Therapy in Health Care, 28(2), 122–126. https://doi.org/10.3109 /07380577.2014.901591 Dickerson, A. E., Schold Davis, E., & Chew, F. (2011, March). Driving as an instrumental activity of daily living in the medical setting: A model for intervention and referral. Paper presented at the conference of the American Society on Aging, Washington, DC. Eade, D. (1997). Capacity-building: An approach to people-centered development. Oxford, England: Oxfam UK and Ireland. Lane, A., Green, E., Dickerson, A. E., Schold Davis, E., Rolland, B., & Stohler, J. T. (2014). Driver rehabilitation programs: Defining program models, services, and expertise. Occupational Therapy in Health Care, 28(2), 177–187. https://doi.org/10.3109/07380577 .2014.903582 Lorenzo, T., & Joubert, R. (2011). Reciprocal capacity building for collaborative disability research between disabled people’s organizations, communities and higher education institutions. Scandinavian Journal of Occupational Therapy, 18(4), 254–264. https://doi.org/10.3109/11038128.2010.525748. McGuire, M. J., & Schold Davis, E. (Eds.). (2012). Driving and community mobility: Occupational therapy strategies across the lifespan. Bethesda, MD: AOTA Press. Organisation for Economic Co-operation and Development, Development Assistance Committee (2006). The challenge of capacity development: Working towards good practice. Retrieved from http://gsdrc.org/docs/open/cc110.pdf Schold Davis, E., & Dickerson, A. (2017). OT–DRIVE: Integrating the IADL of driving and community mobility into routine practice. OT Practice, 22(13), 8–14. United Nations Development Programme. (2009). Supporting capacity development: The UNDP approach. Retrieved from http:// www.undp.org/content/dam/aplaws/publication/en/publications /capacity-development/support-capacity-development-the-undp -approach/CDG_Brochure_2009.pdf Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Starting New Programs 14 Ann Burkhardt, OTD, OTR/L, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ State underlying principles involved in starting a new program in either a clinical or higher educational setting, ■ State a course of action that is based in the format of an accrediting body, and ■ Set priorities for developing services based on the setting. KEY TERMS AND CONCEPTS • • • • • • Accreditation Advisory groups Best practice models Budget Care mapping Certifications • • • • • • Faculty workload Growth plan Lab ratio Needs assessment Policy and procedures manual Practice parameters OVERVIEW C hange has been the occupational therapy profession’s mantra for a long time. Continuously changing in response to societal need, the profession has subsequently grown and developed since its founding more than 100 years ago. The change itself varies by what is driving the change. Educators may change the approach to teaching about a given topic based on changes in education philosophy; the scholarship of teaching and learning; or changes in what is taught and whether the efficacy of the knowledge that has traditionally dominated is challenged or supported by science. Research outcomes and recommendations may drive change in clinical practice, especially when evidence from research modifies the theory that underlies practice assumptions. This chapter discusses commonalities and differences that exist when starting a new clinical program or a new academic program. Clinical programs often change day-to-day tasks such as documentation and billing in response to insurance industry regulations. Therefore, clinical practice models tend to develop when clinical best practice models, often referred to as clinical pathways, emerge to improve clinical outcomes and support the inclusion of evidence-based practice into • • • • Program development Regulations Scope of practice Strategies the clinic. In contrast, academic programs change how clinical concepts are taught in their curricula based on credentialing through their accreditation bodies. Change drives actions taken in professional associations that influence clinical practice. Health care policy research and global assessments of overall health influence professional practice models and suggest recommended change. When society identifies a tipping point in terms of meeting the health needs within a population, professions are poised to shift focus from day-to-day practice to supporting societal needs through program development and implementation of changes in clinical practice care delivery. Clinical directors and academic directors share similar concerns about policy development and the impact of research and policy on program development. ESSENTIAL CONSIDERATIONS Role of Health Policy Clinical practice is often driven by health care policy research and subsequent international agreements that change our conception of what drives health for populations, communities, groups, and individuals. For example, the World Health Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.014 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 141 CHAPTER Starting New Programs 14 Ann Burkhardt, OTD, OTR/L, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ State underlying principles involved in starting a new program in either a clinical or higher educational setting, ■ State a course of action that is based in the format of an accrediting body, and ■ Set priorities for developing services based on the setting. KEY TERMS AND CONCEPTS • • • • • • Accreditation Advisory groups Best practice models Budget Care mapping Certifications • • • • • • Faculty workload Growth plan Lab ratio Needs assessment Policy and procedures manual Practice parameters OVERVIEW C hange has been the occupational therapy profession’s mantra for a long time. Continuously changing in response to societal need, the profession has subsequently grown and developed since its founding more than 100 years ago. The change itself varies by what is driving the change. Educators may change the approach to teaching about a given topic based on changes in education philosophy; the scholarship of teaching and learning; or changes in what is taught and whether the efficacy of the knowledge that has traditionally dominated is challenged or supported by science. Research outcomes and recommendations may drive change in clinical practice, especially when evidence from research modifies the theory that underlies practice assumptions. This chapter discusses commonalities and differences that exist when starting a new clinical program or a new academic program. Clinical programs often change day-to-day tasks such as documentation and billing in response to insurance industry regulations. Therefore, clinical practice models tend to develop when clinical best practice models, often referred to as clinical pathways, emerge to improve clinical outcomes and support the inclusion of evidence-based practice into • • • • Program development Regulations Scope of practice Strategies the clinic. In contrast, academic programs change how clinical concepts are taught in their curricula based on credentialing through their accreditation bodies. Change drives actions taken in professional associations that influence clinical practice. Health care policy research and global assessments of overall health influence professional practice models and suggest recommended change. When society identifies a tipping point in terms of meeting the health needs within a population, professions are poised to shift focus from day-to-day practice to supporting societal needs through program development and implementation of changes in clinical practice care delivery. Clinical directors and academic directors share similar concerns about policy development and the impact of research and policy on program development. ESSENTIAL CONSIDERATIONS Role of Health Policy Clinical practice is often driven by health care policy research and subsequent international agreements that change our conception of what drives health for populations, communities, groups, and individuals. For example, the World Health Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.014 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 141 142 SECTION II. Organizational Planning and Culture Organization’s (WHO) membership includes nations around the world. WHO asks all member nations to share knowledge about approaches to health care delivery within their countries and to share statistics and directionality based on what the evidence demonstrates. The evidence is then used to strategize how international health care policy should shift to deliver more efficient quality care in a defined time frame. The 2017 Bloomberg Global Health Index, based on WHO’s UN Population Division data, ranks the United States as the 34th healthiest country out of 50 (Dhiraj, 2017). The U.S. Department of Health and Human Services reviews these data to further recommend changes in American policy (e.g., Healthy People 2020, use of the International Classification of Functioning, Disability and Health to alter care delivery models). These recommended changes are managed by the Agency for Healthcare Research and Quality (AHRQ). Policy research often results in development of new approaches to care delivery. When service delivery changes, when new populations present themselves in need, or when the focus of care is forced to shift, the demand for more trained professionals to provide care under different circumstances increases. If the demand is significant enough, professions, including occupational therapy, begin to include knowledge about the new practice in entry-level education. Professions also use continuing education as a means to educate occupational therapists who are already practicing in the field. Authoritative rules or directives, called regulations, may mandate new training be incorporated into practice or education. Service Delivery The Bureau of Labor Statistics (2017) states that there will be a 27% shortage of occupational therapists in the United States in the next decade. In recent decades, occupational therapy clinical practice has thrived in traditional practice models such as hospitals, nursing and long-term care facilities, home care, and private practice. Since the 1970s, pediatric practice has been continuously developing and has been offered in hospitals, at home, in schools, and in private practice. Since the 1990s, an increasing number of occupational therapists have identified their role and practice within public health models of care delivery. AHRQ’s current focus is on prevention and chronic care: preventing disease and helping patients maximize health and function over the lifespan (AHRQ, 2015). Consultancy has continued to develop and filter into occupational therapy. This mode of service delivery strengthens practitioners’ roles as changes in practice occur in clinical and higher educational settings. The introduction of the clinical doctorate in occupational therapy has placed the profession in a prospective stance; the scholarly applied-practice and higher education projects that are the outcomes of many doctoral projects have offered possibilities for practice expansion in novel ways. Some new practice settings are fee-for-service based. Others may be grant-funded or nonprofit organizations that offer key services to a targeted population or group. Third-party payment continues to fund the majority of services, but the new generation of occupational therapists also recognizes that diversity of revenue streams not only supports an ongoing presence in traditional markets but also strengthens and supports the inclusion of occupational therapy in developing models of care. Occupational therapy managers must reconsider how traditional practice settings could be alternatively staffed with a minimum of risk, with greater service delivery efficiency, and without creating extended waiting lists or denials of care. For example, if professional-level practitioners work more efficiently and collaboratively with occupational therapy assistants, more people may be served, societal needs may be better met, and the public will not have services delayed or be diverted to other professionals who lack occupational therapy skills for their care. Current practice delivery models may need to be limited if they have become less viable over time. A leap of faith that cutting services in one area will allow for more services in another area where there is more need may be indicated for support of the greater good. Evidence not only applies to the clinical outcomes of what we do but also depends on the economic viability of service delivery when financial resources are limited, especially for the underinsured and underserved (Collins, 2013; Fisher & Friesema, 2013; Robinson et al., 2016; Williamson et al., 2016; Yousey et al., 2012). Evidence is fiscal as well as clinical. For example, the number of older adults in the United States is continually increasing. By 2030, all Baby Boomers will be ages 65 or older, and 1 in every 5 people will be retirement age (U.S. Census Bureau, 2017). Yet, the number of occupational therapy practitioners is finite. As the tsunami of aging (also called the gray tsunami and silver tsunami) increases the strain on the Medicare system, it might be more efficient in terms of cost and human resources if the professional-level occupational therapy practitioner works with a facility as a consultant to assure that the Centers for Medicare and Medicaid Services (CMS) guidelines are followed. At present, the occupational therapist should complete the initial evaluation, subsequent reevaluations, and the discharge documentation. The occupational therapy assistant should provide as much of the 1-to-1 direct care with clients as possible. The therapist provides the services that the assistant may not complete. Therapists should retain evidence of training for the assistants with whom they work to ensure that clinical competence is verified and tracked. Occupational therapists should not regularly engage in direct daily client service delivery unless the professional level of skill is warranted for a specific evaluation, treatment, or device prescription. In the near future, therapists in such settings will be best used if they focus on management and consultancy for service delivery and follow through with quality improvement and service delivery measures. Case Example 14.1 provides case scenarios for starting programs in clinical settings. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 14. Starting New Programs 143 CASE EXAMPLE 14.1. Starting Programs in Clinical Settings Scenario 1 You work as the manager of clinical services in a university-based medical center and have an opportunity to expand occupational therapy services into a liaise-focused position with the United Way. The medical center does internal fundraising and requests that employees financially support the United Way. 1. What are the pros and cons of the proposed relationship? 2. How would you organize the development of the relationship for both clinical expansion and student training? Scenario 2 You have been hired to develop occupational therapy services in a primary care center that is affiliated with a tertiary care university-based medical center. The rehabilitation department has had a long-standing physical medicine service with a physical therapy department and 1 part-time speech pathologist. There is also a psychiatry unit. 3. What would you propose for implementation of occupational therapy services? Scenario 3 The opioid crisis has hit your community very hard. The rate of suicide associated with opioid overdose has skyrocketed. Your community has contacted potential stakeholders to create a community response and develop intervention programming. 4. What could you propose as occupational therapy–targeted interventions to work on this in an interprofessional way? Scenario 4 You are a manager in an acute care hospital. The director of managed care has requested a list of all the skilled experience of the occupational therapy staff. 5. How might you develop a system for tracking this information? 6. How could you identify other stakeholders who may also benefit from access to this information? Scenario 5 You are an occupational therapist who works in a subacute-care setting in a rural community. You are aware that CMS has changed the coverage and rules about care delivery for skilled and maintenance care in all subacute-care facilities. 7. How would you communicate this to the administration overseeing rehabilitation services? 8. Does this change result in a loss of staffing for the facility? 9. How would you determine what services could be expanded to deliver best care to the clients? 10. Where would you look for guidance and networking about this? Starting a New Clinical Occupational Therapy Program Before taking on the role of manager, consultant, or director of a service, an occupational therapy practitioner should develop skills and competence to enter the managerial role. There is a transitional process from being a clinician to being a manager (Politano, 2013). Occupational therapy professional associations offer training and networking venues for people who are becoming or working as managers. Institutions often offer internal training for managers and supervisors through their human resources or staff training departments. Some institutions have partnerships with local colleges and universities, and they may even fund part of a degree, such as one in public health administration or hospital management, to support managers in their role. It is helpful to seek training in one’s home work site or setting, if possible. Online courses are available as continuing education or for academic credit. Attending trainings and conferences provide good networking opportunities to meet others in the audience or approach speakers. Some of these may have valuable information to share about developing management skills. Finding a mentor and listening and learning are key. After becoming a manager and gaining skills, mentor others. In established clinical settings, if day-to-day practice remains the same for day-in/day-out care delivery and does not change over time, practice stagnates. Traditionally in hospital settings, cost containment measures force changes in day-to-day care delivery. Some of these are a result of reimbursement changes that occur with legislated health care reform. Others occur as a result of an adoption of management models, such as Six Sigma or Lean, to reengineer care delivery processes (Neufeld et al., 2013). Needs assessment In clinical settings, managers should periodically do a needs assessment to determine whether the care they deliver is relevant and that evidence exists that there is sufficient revenue to more than cover expenses for the setting or institution (Improta et al., 2015). A needs assessment is a systematic approach used to identify gaps between current practices and desired practice conditions to determine a course of corrective action. Involving employees from inside and outside of the unit being reviewed can be insightful. Progressive plans and actions can assist with keeping practice in sync with societal needs as change is occurring. Introducing novel programming or developing successful grant-funded programs is another path one may pursue (Von Eiff, 2015). Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 144 SECTION II. Organizational Planning and Culture Key players Occupational therapists may ask or be asked to develop services in a setting where services have not previously been established. In a setting where occupational therapy is not the sole service, key players in the setting should be interviewed. Establishing services may depend on the interprofessional team’s perception of what services are missing. Gaining insight into the direction that the team has in mind is an important factor to successful integration of new services in an established microcosm. Strategy All organizations have a vision and a strategy for how change will occur. Strategies require a plan inclusive of goals and objectives, which depend on a mission (Braveman et al., 2011). The plan for a department and a service, such as occupational therapy, should be developed, and its implementation should be incorporated into the department or service’s strategic plan. Accrediting agencies will look for this link to be formalized in the department’s policy and procedures manual and cross-referenced in the institution’s documents. Practice parameters and scope of practice Occupational therapy is based on concepts of practice parameters (i.e., what one does typically daily in a setting) and scope of practice (i.e., possible services that one could offer within a setting). Practice parameters are often closely connected with roles a professional group assumes in that setting. Some aspect(s) of care delivery could be accomplished by several team members, so making a calculated move in program development—that is, conceptualizing, formulating, starting, improving upon, or expanding educational, service delivery, or managerial-oriented work plans—could potentially overstep into another profession’s practice in that setting, leading to dissonance and perceived competition. When the roles and tasks in a setting are familiar, there is often comfort in including those roles and tasks into a new care delivery model. However, if everything built into a program maintains the status quo, it can detract from including novel practice within the care delivery model. Managers who are developing clinical services need to keep all of the parameters in mind, be attentive to new programs in development, and advocate for occupational therapy to function meaningfully and effectively within the team (Collins, 2013; Fisher & Friesema, 2013; Leland et al., 2014; Persch et al., 2013; Robinson et al., 2016). Best practice models In hospital-based settings, the evidence-based practice movement supports efficient care delivery, which often includes best practice models and clinical pathways. Best practice models are techniques or methodologies that have proven to reliably lead to a desired result and are often based on research and experience. Common examples include joint replacement models of care delivery and cardiac surgery care delivery models. Within care mapping, the systemized sequence of health and specified related services a patient receives after entering the system during a specific episode of care (“Care map,” n.d.), what one does for a client is often prescriptive. There is not much room for creativity in how care is delivered. Standards have been developed by the National Academies of Sciences, Engineering and Medicine, Health and Medicine Division (2011) to develop trustworthy clinical practice. These include ■ ■ ■ ■ Establishing transparency, Managing conflicts of interest, Setting guidelines for development group composition, and Establishing and systematically reviewing evidence to verify that care provision actually works; the clinical practice guideline–systematic review process includes establishing evidence foundations for and rating strengths of recommendations, articulating recommendations, undergoing external review, and updating. Certifying organizations Certifying organizations also play a role in how institutional settings are guided in practice and how they function; these organizations grant accreditation, a formal process used to determine if an academic institution or program is minimally in compliance with a prescribed sets of standards. The United States currently has 5 health care accreditation organizations: 1. 2. 3. 4. Utilization Review Accreditation Commission, National Committee for Quality Assurance (NCQA), The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), and 5. Council on Accreditation. Those with specific reference to occupational therapy programming are TJC, CARF, and NCQA. Hospitals voluntarily pursue TJC accreditation. The Joint Commission is an independent nonprofit organization that accredits 21,000 health care organizations and programs (TJC, 2017). A manager has to be a part of the administrative group that assures the TJC standards are followed in the department settings. All department members are expected to work with their manager to ensure that standards are met or exceeded. Some rehabilitation settings may also carry accreditation by CARF (CARF, 2017). For Additional Learning For additional learning, see Chapter 55, “Major Accrediting Organizations.” Policy and procedures manual When starting a new program in a clinical setting, managers generally develop a policy and procedures manual (PPM) containing an index, sections according to topic, step-by-step instructions, and information about official department and institution policies. Some of the typical sections included in a PPM are listed in Exhibit 14.1. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 14. Starting New Programs EXHIBIT 14.1. Typical Sections of a Policy and Procedures Manual ■ Safety procedures ■ Environmental management ■ Material data sheets (i.e., copies of safety information concerning ■ ■ ■ ■ ■ ■ ■ all solvents and chemically active agents used in the setting) Work scheduling and time-off requests Telephone roster and a phone tree for emergency communications Pay schedules and procedures Emergency management information Infection control Employee safety and workers’ compensation instructions Commonly used forms (i.e., samples of paper and electronic forms) The PPM also includes specific policies to the program itself. The PPM is generally a living document that changes over time. It is under continuous revision and is regularly updated. In some hospital settings, each policy or procedure must be reviewed yearly, and the review should be initialed and dated (a best practice). If any covering occupational therapy practitioner were to work at the site, they should be able to find the information needed for efficient and effective care delivery by looking up the procedure in the manual. Most manuals today are stored electronically in the institution’s internal website. Budget A budget is generally distributed to a manager by an administrator. A budget is an estimate of income and expenditure for a set period of time. Budgets generally begin with each fiscal year and end the day before a new fiscal year. Within systems of care delivery, such as hospitals, budgets are set at an ideal level. They are upwardly or downwardly adjusted quarterly in systems to determine the need to shift funding from one department or project to another as determined by an administrator. The bottom line nominalization in budgets is intended to be a baseline. Institutions attempt to remain in a positive variance throughout the year, for fiduciary accountability. In general practice, managers are expected to adhere to their budget. If there is a need to exceed the budget, the manager work with their administrator to achieve a solution. An administrator can move funds from one department to another to cover unforeseen expenses if another unit has a surplus or unspent funds. The occupational therapy manager needs to review and track supplies and expenditures and oversee the budget in a fiduciary manner. In hospital settings, occupational therapy budgets can be in the millions, when salaries, benefits, supplies, and other expenditures are accounted for. An occupational therapy manager generally see the salaries and benefit costs for each position they are managing. For More Information See Chapter 50, “Developing a Budget,” for more information on budgeting. 145 Goals and continuing competence One of a manager’s most important functions is to ensure that each staff member has goals for their job and overall career and a plan to pursue those goals. Continued competence is a high value among health care professionals. TJC also mandates that health care professionals have a professional development plan. Many clinical settings also require their occupational therapy professional staff members to remain current with the National Board for the Certification in Occupational Therapy (NBCOT) continuing certification. Activities to work toward continuing competence often have financial and staffing ramifications. The manager is responsible for covering staff absences that support their work on continuing competence. In this capacity, the manager may also act as a mentor and encourage their employees to continue their education; pursue opportunities to contribute to evidence-based practice (e.g., grant-funded interdisciplinary research); participate in continuing education; and mentor students and junior clinicians, providing lectures or pairing with programs, such as educational; community-based consumer-­ oriented; or professional, that support those they serve. ® For More Information See Chapter 54, “Continuing Competence,” for more information on continuing competence and professional development. Starting a New Academic Occupational Therapy Program Similarities exist between starting and managing clinical and academic programs, but distinct differences occur as well. Academic programs are developed according to the type of college or university (e.g., community college, university) that wants to offer occupational therapy as a course of study. The Carnegie Classification of Institutions of Higher Education (2017) provides definitions, classification descriptions, and the methodology (flowcharts illustrating the 6 all-inclusive classifications) for classifying colleges and universities. The types of degrees awarded are also related to these classifications. In some states, the college or university can include an entry-­level course of study if the program can receive accreditation from the regional accrediting body and the professional accrediting body. Currently, post-professional occupational therapy programs are not accredited by the national accrediting body, the Accreditation Council for Occupational Therapy Education (ACOTE) but must be accredited by the regional accrediting body for the institution. Case Example 14.2 provides case scenarios for starting education programs. ® Consultants Many institutions of higher learning hire a consultant in advance of filing a letter of intent to start a program. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 146 SECTION II. Organizational Planning and Culture CASE EXAMPLE 14.2. Starting Educational Programs Scenario 1 You have earned your doctoral degree and have been teaching as an adjunct professor at several occupational therapy and occupational therapy assistant programs in your region for the past 5 years. You are considering changing your primary work focus to academia. 1. How would you prepare for your search for a position? Other than having earned a doctoral degree, what additional goals and skills do you need to include in your professional development plan to make this transition? Where could you turn for advice or mentorship? Does your CV reflect your experience in higher education? 2. Make a list of the lectures you have given, the technology you have used in the classroom, and the networking you have done to prepare (think about professional organizations, memberships, networking, etc.). 3. Create 5 goals with time frames to assist in your pursuit of a position. Scenario 2 You are the program director of an associate degree–granting occupational therapy assistant program. You and the educational administration at your community college have been discussing developing a bridge program to a bachelor’s degree program. 4. What strategies would you suggest to preserve the ability to continue to train occupational therapy assistants while retaining compliance with ACOTE standards? 5. What other institutions could you collaborate with to create that bridge? Scenario 3 You are the program director of a master’s-degree program in occupational therapy. You must develop a plan to transition the program to a doctoral entry-level program and determine whether it is possible at your university. 6. Where would you seek guidance about degree granting and institutions? 7. According to the ACOTE Standards (ACOTE, 2018), what are the differences between a master’s-degree program and a clinical doctoral program? 8. What factors determine when and whether you can continue to admit students and bestow the master’s degree? Scenario 4 You have been approached by an executive search term to apply and interview at a university that is interested in starting an entry-level clinical doctorate in occupational therapy (OTD) program. 9. What would you need to find out in advance of the interview? ■ What questions would you want answered before deciding whether the university would be a good fit for offering an OTD program? ■ What infrastructure is needed for the program to thrive? Consultants may be asked to develop a curriculum plan and a business plan to inform the administration’s consideration of the feasibility of the program. Some of the information needed will include guidance for what fiscal and physical investments are required to develop and support the program (e.g., adequate space and equipment, support services, administrative and faculty personnel). Some universities and colleges hire a consultant who has specific knowledge of ACOTE requirements and candidacy application development during the candidacy application process. Consultants may have been ACOTE members or reviewers and, therefore, usually have a broader perspective in terms of the information that is being sought in the application. Consultants may do this in a part-time or full-time role; their time can be contracted for a set number of hours. This is a good practice overall because the external consultant often has insights that a program director, academic fieldwork coordinator (AFWC), or other hired faculty may not have. Gaining perspective can be a challenge if a program director has developed a previous academic program, if the institution is not equivalent in Carnegie classification status, or if the culture of the university or college is distinctly different. ACOTE contact After the administration commits to a plan, the institution submits a letter of intent to ACOTE to develop a program. ACOTE will establish a time frame for a candidacy application review and approval. After the letter is filed, the institution must submit a completed candidacy application within a set time frame (issued by ACOTE) to achieve candidacy status. Administrative collaboration At a minimum, a program director and an AFWC should be hired to work with the administration to complete the candidacy application. The committee that is formed to hire a program director often includes faculty members from the college that will house the program or members of the university. Many colleges invite members of the local occupational therapy community to be part of the selection committee for the new program. Soon after the program director and AFWC are hired, they should be given membership on departmental, college, and university committees to gain service to the college and Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 14. Starting New Programs community and to support their own applications for eventual promotion, if applicable. As they develop a program, the occupational therapy faculty will need to interface with key university-wide committees, such as those for curriculum and outcomes. The faculty will also have expectations for service to the university community (e.g., committee participation, service engagement, mentorship/mentee program inclusion). Only some higher education institutions offer tenure. Other institutions may have expectations for service to the institution, but there may not be any formal, defining expectation of how much service or scholarship is required to sustain an appointment. The tenure process or academic advancement information is generally found in a faculty manual. All faculty should read the manual at or before starting a position. Candidacy application The ACOTE candidacy application generally takes months to complete. The application is electronic, password protected, and made through an online portal. After the institution pays its fees and establishes its intent, ACOTE staff issues access to the portal and informs the institution’s representatives of the due date for the completed candidacy application. The institution’s program faculty, dean, provost, and president all give input in the application and review the application before it is filed. Each ACOTE Standard has a page in the application. Substantiating documentation is submitted in PDF format to offer examples of policies and provide copies of faculty credentials, for example. The program director and AFWC must possess the credentials defined by ACOTE to be in compliance with ACOTE accreditation standards. The Standards (ACOTE, 2018) should be referred to at each step in developing the document. The document also must demonstrate congruency among the strategic plan, vision, and mission of the university and the college. The program director and AFWC should monitor ACOTE actions. It is possible that proposed standards may replace current standards while the application is in progress. In this case, the application may need to reflect changes in the application process (e.g., the program may be approved for candidacy and working toward the self-study document; however, the new requirements may include additional documentation or information that must be included in the self-study before it is submitted). The application is detailed and somewhat complex. ACOTE offers a training seminar several times a year to instruct program directors on how to prepare the application and to engage and enculture them into the process. The seminars are generally offered before Academic Leadership Council meetings and throughout the year. Some may be scheduled in between meetings when the demand is high and the seminars sell out. In the recent past, the seminars have filled to capacity. 147 Unions When setting or developing policies for faculty, which are shared with ACOTE (e.g., through professional development plans), it is important to have knowledge and understanding of the structure within the university that governs day-to-day work, ACOTE requires candidacy applicants to share workload expectations. Workloads have to be consistent with university policy and should also be reasonable and in line with other occupational therapy academic programs in other colleges or universities that are similar in structure. The faculty labor environment often dictates these policies, which are then included in faculty handbooks or similar documents. Faculty at a college or university faculty may or may not be unionized. The American Association of University Professors (AAUP; 2017) is a nonprofit organization of faculty and other academic professionals. Chapters are based at colleges and universities across the country. There are 2 sister organizations: the AAUP Collective Bargaining Congress, which is a labor union; and the AAUP Foundation, which funds charitable and educational purposes of the AAUP. Whether an institution is organized or not, the AAUP policies and rules are generally followed in most academic institutions. Peer faculty mentorship Peer faculty mentorship is also valued at some academic institutions. If one works in an environment where faculty development is encouraged, having a mentor who “knows the ropes” can often provide a path to success for a new faculty member. Mentorship can ease adjustment to new ways of working and increase the probability for success. A peer mentor helps the new faculty adjust to the campus environment, practices, and values. Even before the ACOTE candidacy papers are filed, it is important to establish inclusion of the faculty and obtain support from the college community for the program’s development. Programs cannot develop without community-wide support. Program housing Some occupational therapy programs are housed with physical medicine and rehabilitation programs, others with schools of pharmacy and allied health, some with colleges of education, and some with colleges of health and wellness. Institutions generally have historic precedents that can give insight into why that college developed and why the program is housed within a given college. Space will need to be identified for the program. Potential on-campus buildings may require remodeling to provide an acceptable environment for labs and classrooms. If space is not available on campus, the university must consider either purchasing a building (or space within a building) where the program could be housed or building a new environment for the program. Faculty members, staff, and interprofessional departments that will work closely with the program should be included in any building or remodeling project to ensure Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 148 SECTION II. Organizational Planning and Culture that the space will be able to be used for the purposes intended and will adequately supply the demands of use (e.g., electrical demands, WiFi and cabled computer wiring, splinting spaces, pediatric sensory labs, special sinks or plumbing, functional and traditional lab spaces and equipment, accessibility of spaces, storage). It will take at least a year to plan and construct the space, so this should be completed early in the program’s development on campus; contingency space may need to be defined before construction begins. It is shortsighted to assume that standard classrooms and bench labs will be adequate for educating occupational therapy practitioners. The occupational therapy faculty may need to advocate for the contextual needs of the field of study and the proper environment to support it. Admissions Sizes of student cohorts are set in advance, usually in the initial program business plan. Admissions cannot be opened until accreditation is established. Students who apply should be informed of the program’s status when they apply. Even with candidacy, if a program fails during its self-study phase, the students will not be eligible to sit for the NBCOT exam with an entry-level degree. Without this credential, students cannot become licensed to practice. Most academic institutions will support their programs and work responsibly to ensure accreditation. If an institution lacks access to resources, especially financial, to build and support a program that can meet accreditation standards, then the program may not be able to progress to full accreditation status. After a candidacy application is accepted and ACOTE grants candidacy status, admissions must proceed to have an opportunity to recruit a viable cohort of qualified candidates. Admission to occupational therapy programs has been aided with the creation of the Occupational Therapy Centralized Application Service (OTCAS). A relationship with OTCAS can be established before candidacy is sought so the platform is ready to accept applicants as soon as candidacy is granted. Visibility and viability are necessary to favorably market programs and attract candidates. All programs must develop web presences. Marketing groups within the academic institution generally use strategies that they have determined work best to appeal to candidates who are drawn to their program and similarly ranked institutions. Often, there are also differences in how on-ground programs versus online programs are marketed. Admission processes differ from institution to institution and from program to program. Some occupational therapy programs no longer have face-to-face interviews and rely solely on the OTCAS application. Other programs have a variety of admission experiences ranging from a 1-to-1, face-to-face formal verbal interview to multimodal interviews that may include activity-embedded tasks that give insights into problem solving, insight, personal motivation, and teamwork. With developing programs, a decision must be made on process. If students may be concerned about entering a program with candidacy status that is not yet accredited, a face-to-face, on-campus visit may be the best choice. If they can see the campus, witness the culture and environment, and meet the professors and support staff, they are often reassured. Such visits may make the difference in deciding their choice of college or university. OTCAS allows a program to communicate with applicants who have the credentials and profiles that administrators seek, and admissions staff can encourage potential candidates to apply. Members of the program’s admissions committee can access applicants and choose those who meet the admission criteria (e.g., grade point average, writing style, adequate shadowing experiences, Graduate Record Examination scores [GRE]). Application deadlines vary. In recent meetings of occupational therapy academic leadership, some programs have broached the desire to standardize a universal application deadline, but this had not advanced in action or discussion at the time of this writing. For some programs, rolling admission until a cohort is filled is the only viable approach. Some applicants may accept admission and submit deposits but will accept a position at their first-choice institution if they gain acceptance after the deadline or are advanced to candidate status from a waiting list. Admission is a dynamic process, and each program has to determine within their setting the admission guidelines that offer transparency to fairness and access of diverse student groups. If a program uses a formal interview process on the grounds, it may be helpful to develop a supporting group to assist with the admission process. For example, beyond including the faculty and admission representatives, consider including members of the program’s advisory council, members of the consumer community, faculty from associated university programs, and clinical partner groups from nearby universities (medical faculty in local medical schools and members of physical therapy or speech–pathology programs, if they are not a part of the campus community). Teaching assignments and schedule After a cohort has been accepted and confirmed, the program director and occupational therapy faculty have to plan for the teaching assignments and schedule. ACOTE requires the institution to share policies about workload and staffing plans. If they do not demonstrate a commitment to providing an adequate number of instructors for courses, the program could be cited during the assessment process. An ongoing concern is the shortage of qualified higher education instructors in the field of occupational therapy. Recruiting experienced faculty can be challenging. Some general considerations are that a program director in occupational therapy should be held to the same standard within the institution as a peer professional. Their workloads, committee assignments, office space, and access to financial resources should be equivalent. Growth plan. Institutions should have a commitment to a growth plan, if the business plan reflects an anticipated yearly increase until the maximum cohort size is reached. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 14. Starting New Programs There should be a plan to hire additional faculty yearly until the cohort size and student-to-faculty ratio match. There may be administrative and non-administrative faculty. Administrative faculty lines tend to be non–tenure track lines. These faculty members may have less job security than that of the general faculty, and their liquidity of time may vary from that for full-time academic faculty, but administrative faculty often have reduced teaching loads to balance their workload. In many institutions, administrative faculty are expected to be on campus daily for the full business day. Full-time academic faculty have greater liquidity of time and generally are expected to be on campus to teach, have office hours, attend training, and fulfill committee obligations. Some institutions demand physical presence at committee meetings. Other institutions use virtual meeting platforms and encourage attendance in person or virtually. Occupational therapy programs with multiple sites often use virtual platforms for committee meetings. Other instructors. Programs can use adjunct faculty and specific topic lecturers, lab instructors, and others to balance the instruction within courses and to ensure that there are adequate vetted faculty who can instruct. In most institutions, the title of adjunct faculty implies that the institution employs that level of instructor. Positions for adjunct instructors may have to be posted, applicants sought, and positions formally offered to the individual candidate through the institution’s human resources process. Clinical instructors (CIs) may be part of the full-time faculty. CIs may be offered opportunities for advancement. Some university-based medical centers give CIs assistant- or associate-­level appointments. There are usually guidelines that help determine an appropriate rank based on the applicant’s curriculum vitae. CIs may be given release time from their regular job hours to teach for the university. A CI who is given release time cannot be paid additionally for the teaching time (they are not allowed to “double dip”). Many CIs will take paid time off and use their own time, versus the hospital’s time, to teach. Lab ratio. Lab ratio also must be defined institutionally, and numbers are often based on peer laboratory groups for other professions. Adequate instructors and lab sessions are needed to ensure student-to-faculty ratios are preserved. The plan for staffing labs will also affect the faculty workload. Faculty workload. A careful balance is required when plan- ning for faculty workload. Some institutions will pay faculty to work overtime. If faculty cannot accept the additional hours, more instructors will need to be hired. Adequate funding must be in the budget to plan for this inevitability. Deans and provosts must demonstrate a commitment to the faculty and the program for these circumstances. Deans and provosts can look at the university’s overall budget and move resources from one program to another based on demands. The program director must have oversight on this and seek what is needed for program support. 149 Faculty recruitment When recruiting faculty, program managers should consider degree and skill diversity among faculty members. Occupational therapy educators may hold the following degrees: master’s-level education at the associate-degree program, a proportion of master’s to doctoral education for the master’s-­ degree program, and a doctoral degree for the doctoral-­ degree program. Occupational therapy practitioners choose a variety of terminal degrees when they become educators. Currently, a doctoral degree is a terminal degree. There are also considerations for research versus non-­ research degrees. For example, clinical doctorates generally are not considered research degrees. Some academic institutions require that faculty have research degrees, while others do not. Some individuals have education degrees, such as the educational doctorate (EdD). The EdD is often considered a research degree. Some occupational therapists aspire to careers as leaders in education. An EdD may position them well to seek promotion within universities to positions such as assistant dean, associate dean, or dean. If they continue to gain competence in academic leadership, they could work for further advancement within the university. Faculty members may also take on roles within the faculty of the university, such as seek election to the faculty senate. Faculty with doctoral degrees often advance in university-wide academic community prominence. Degree diversity can strengthen a department by having the presence of many with diverse knowledge and experience. Finally, faculty should represent a variety of clinical practice experience. Practice currently has avenues for obtaining advanced clinical or board certifications. These certifications require specific training and experience and verify that the holder has a specific set of skills and knowledge. Emerging practice also needs to be represented. Faculty may need to be part of the fieldwork experience for students in emerging environments when placements cannot be offered because there are no current mentors. Educators need to be prepared to lead in the development of new practice. Advisory groups Academic programs have advisory groups comprised of members of the professional and academic community. Some ad­ visory groups also include community stakeholders. Potential members of an advisory group may be nominated and contacted to determine their willingness to serve in this capacity. Best practice is to have several meetings per year. Advisory board members should be informed about overall program operations, the program application in progress, the curriculum as it is being developed, and the status of student applications and admissions. Advisory board members may also serve as a link to resources in the practice community. Clinicians have a stake in ensuring that there will be a flow of trained and educated professionals to enter and sustain the practice environments and meet the needs of their communities and populations of service. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 150 SECTION II. Organizational Planning and Culture Some universities have a national presence on their advisory board. Alumni also often serve on advisory boards for the programs from which they have graduated. Universities with large endowments may have funding to pay expenses for advisory board members to physically be present at meetings. Virtual platforms such as Skype or Zoom allow for participation of advisory board members who live or work at a distance. Review Questions 1. If you were starting a new occupational therapy program in a clinical setting, which 3 parameters should shape your decision making and direction of development? a. A needs assessment, scope of practice, and practice parameters within an interprofessional team b. How many people in the setting know about occupational therapy, how welcoming the people are to the presence of occupational therapy, and perceived competition c. Financial considerations, restrictions on practice, and billing procedures d. Billing, reimbursement, and the ability to say the facility has an occupational therapist 2. What is a shared value between developing programs in clinical and educational settings? a. Current non–occupational therapy employees can act on behalf of the occupational therapy presence to establish a need for a program b. Occupational therapy practitioners in both settings need to have professional development plans c. Job security in both settings depends on union rules and tenure d. Occupational therapy practitioners are never in charge or serve in administrative positions 3. Which occupational faculty member is most visible in clinical settings? a. The program director b. The AFWC c. Neither; they both work out of the college or university but do not make site visits d. Both PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Even skilled and experienced program developers can benefit from oversight and advice. Exhibit 14.2 provides an overview of practical considerations for occupational therapy managers starting new programs. Unions In organized work environments, practitioners may be union members. When a new department is developed, the union will be interested in recruiting staff. Therapists generally have a higher earning potential than other rank-and-file members, EXHIBIT 14.2. Practical Considerations for Starting New Programs ■ Understanding the overarching systems where we work and manage services is key to our inclusion and success in those settings. ■ An understanding of management within the context of occupational therapy is a part of entry-level education. ■ Program development relies on a foundation of knowledge of management principles. ■ It is important to have an ability to understand budgets and the mathematics associated with billing and remuneration. ■ Planning for growth and development is important when developing both clinical and educational departments. ■ Building skills as a manager is important for practitioners who wish to advance in either a clinical or an educational setting. ■ Networking skills are paramount. Know where to find consultants to help you, if the work is out of the scope of your own skills and level of understanding. Consultants can offer insights into how other successful programs operate and strategies that are recognized as being successful. and their presence in the union elevates the stakes for negotiating. Their presence also has financial ramifications; union dues are a gain for the union, and an increase in numbers can also lower the per-member cost for benefits such as medical insurance. In these settings, the manager generally is given training in managing in an organized labor environment. Any disciplinary action with an employee may require a union representative to be present at the meeting. Documentation is kept and added to the employee’s file. The member may file a grievance against management for the action. The process may not be expedient and may be extended before any outcome occurs. Fieldwork Professionals have an expectation of serving as mentors to those who are entering the profession. With efficiency standards at an all-time high, there has been some reluctance in new clinical settings to include students during the program development process. Fieldwork and doctoral-level capstone experiences can enrich the development process and bring fresh eyes, contemporary knowledge, and evidence into the process. In the current clinical environment, with a simultaneous shift in occupational therapy higher education, the manager will work with the clinical fieldwork advisory groups to discuss whether the setting can train all levels of clinical practitioners. In addition to the traditional Level I and Level II fieldwork, doctoral project placements (which are technically not fieldwork) still require a site mentor to work with the occupational therapy doctorate. Staying informed and trained in changes in administration and management roles as well as clinical fieldwork management roles is essential to support professional practice and to bring new concepts, ideas, and programming to the clinical site. In occupational therapy, AOTA’s Special Interest Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 14. Starting New Programs Sections (SISs) provide specific training and continuing education that addresses these skill development and networking needs. Advancement Occupational therapy leaders can advance within practice settings. Beyond being a department manager, occupational therapy practitioners can advance into practice management and administrative roles. Practitioners may advance to roles that involve administration of larger groups inclusive of the occupational therapy presence, such as orthopedic services, surgical services, and neurological services. Some of these leaders in management may advance their degree presence and take on higher-level leadership roles, such as vice president, president, and chief executive officer. Review Questions 1. CMS has announced a major change in how occupational therapy services will be delivered and reimbursed in sub‑acute rehabilitation and long-term care settings. How would you approach this announcement and plan for change in the environment you manage (as a clinical manager or as an academic manager)? 2. With the advent of the tsunami of aging, the numbers of persons ages 65 or older who will seek occupational therapy care will rise exponentially. Dementia management is a major focus of care delivery. What steps would you take to develop a plan for inclusion of occupational therapy services in dementia management that encompasses the education and training of both practicing clinicians as well as students who are entering the profession? List who would be a part of your networking group. 3. You are a new academic program director in an academic setting. Describe what you would do to build a professional advisory council to advise you and your faculty while developing the program. Who would you want to compose the committee, and how would you identify the people for this group? SUMMARY Developing new programs takes a pioneering spirit. The process is never static. Standards dictate the parameters in which practice occurs. Changes in standards occur over time. A leader, whether in a clinical or and academic setting, has to monitor trends and anticipate changes in day-to-day operations over time. They have to include and delegate process changes to those who work with them. Teamwork supports changes in both clinical and higher education settings. Networking within and external to one’s profession is necessary to monitor trends, gain insight from what others are doing, and provoke thought processes and potential actions that can support the structure of the work environment as change occurs. Knowledge of systems and flow processes is essential to establish goals, build systems, and have a successful outcome. ❖ 151 LEARNING ACTIVITIES 1. Identify the regional or national career accrediting body for your college or university (or your alma mater if you have graduated). Identify some of the strengths and limitations of your institution. Read the summary from the most recent report from the regional accrediting body to see if it agrees with your evaluation. 2. Identify the role of the occupational therapy department or program in the last regional accreditation review. If the department or program was not an active participant, find out who was involved. Determine how the occupational therapy program could participate. Attempt to secure a role on the planning committee for a representative from occupational therapy so there is representation in the planning process and inclusion in the next review process. 3. Discuss with your professor or program director the ACOTE process for your program. 4. Identify the strengths and limitations of your educational program. Ask your professor or program director to share with you the ACOTE report to see if your thoughts agree with those of ACOTE. 5. Accreditation relies on volunteers from the profession. ACOTE’s Roster of Accreditation Evaluators includes volunteers from both practice and academia. Identify the requirements, including training, to be an evaluator. ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ B.5.0. Context of Service Delivery, Leadership, and Man■ ■ ■ ■ ■ ■ ■ ■ agement of Occupational Therapy Services B.5.2. Advocacy B.5.3. Business Aspects of Practice B.5.4. Systems and Structures That Create Legislation B.5.5. Requirements for Credentialing and Licensure B.5.6. Market the Delivery of Services B.5.7. Quality Management and Improvement B.5.8. Supervision of Personnel B.6.4. Locating and Securing Grants. REFERENCES Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org /10.5014/ajot.2018.72S17 American Occupational Therapy Association. (2017). ACOTE 2027 mandate update and timeline. Retrieved from https://www.aota .org/Education-Careers/Accreditation/acote-doctoral-mandate -2027.aspx Agency for Healthcare Research and Quality. (2015). Prevention and chronic care. Retrieved from https://www.ahrq.gov/professionals /prevention-chronic-care/index.html Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 152 SECTION II. Organizational Planning and Culture American Association of University Professors. (2017). About the AAUP. Retrieved from https://www.aaup.org/about-aaup Braveman, B., Baize, C., Malacara, M., Morris, G. S., Munoz, L., Scheetz, J., & Wright, D. (2011). Strategic visioning and planning: The MD Anderson Cancer Center Department of Rehabilitation Services Experience. Administration and Management Special Interest Section Quarterly, 27(4), 1–4. Bureau of Labor Statistics. (2017). Occupational outlook handbook: Occupational therapists. Retrieved from https://www.bls.gov/ooh /healthcare/occupational-therapists.htm “Care map.” (n.d.). Retrieved from https://medical-dictionary.the freedictionary.com/care+map The Carnegie Classification of Institutions of Higher Education. (2017). Definitions and methods. Retrieved from http://carnegie classifications.iu.edu/definitions.php Collins, L. (2013). Positioning occupational therapy in a changing health care landscape. Administration and Management Special Interest Section Quarterly, 29(4), 1–2. Commission on Accreditation of Rehabilitation Facilities. (2017). About CARF. Retrieved from http://www.carf.org/About/ Dhiraj, A. B. (2017, April 19). The list of the world’s 25 healthiest countries may surprise you. CEO World Magazine. Retrieved from http://ceoworld.biz/2017/04/19/list-worlds-25-healthiest-countries -may-surprise/ Fisher, G., & Friesema, J. (2013). Health Policy Perspectives— Implications of the Affordable Care Act for occupational therapy practitioners providing services to Medicare recipients. American Journal of Occupational Therapy, 67, 502–506. https://doi.org /10.5014/ajot.2013.675002 Improta, G., Balato, G., Romano, M., Carpentieri, F., Bifulco, P., Russo, M. A,, . . . Cesarelli, M. (2015). Lean Six Sigma: A new approach to the management of patients undergoing prosthetic hip replacement surgery. Journal of Evaluation in Clinical Practice, 21, 662–672. https://doi.org/10.1111/jep.12361 The Joint Commission. (2017). About the Joint Commission. Retrieved from https://www.jointcommission.org/about_us/about _the_joint_commission_main.aspx Leland, N. E., Crum, K., Roberts, P., & Gage, B. (2014). Health Policy Perspectives—Advancing the value and quality of occupational therapy in health service delivery. American Journal of Occupational Therapy, 69, 6901090010. https://doi.org/10.5014/ajot.2015.691001 National Academies of Sciences, Engineering and Medicine. (2011). Standards for developing trustworthy clinical practice guidelines. Retrieved from http://www.nationalacademies.org/hmd /Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust /Standards.aspx Neufeld, N. J., Hoyer, E. H., Cabahug, P., González-Fernández, M., Mehta, M., Walker, N. C., . . . Mayer, R. S. (2013). A Lean Six Sigma quality improvement project to increase discharge paperwork completeness for admission to a comprehensive integrated inpatient rehabilitation program. American Journal of Medical Quality, 28(4), 301–307. https://doi.org/10.1177 /1062860612470486 Persch, A. C., Braveman, B. H., & Metzler, C. A. (2013). Health Policy Perspectives—P4 medicine and pediatric occupational therapy. American Journal of Occupational Therapy, 67, 383–388. https://doi.org/10.5014/ajot.2013.674002 Politano, C. (2013). It’s not just a job: Fostering a career-oriented occupational therapy department. Administration and Management Special Interest Section Quarterly, 29(1), 1–4. Robinson, M., Fisher, T. F., & Broussard, K. (2016). Health Policy Perspectives—Role of occupational therapy in case management and care coordination for clients with complex conditions. American Journal of Occupational Therapy, 70, 702090010. https://doi.org /10.5014/ajot.2016.702001 U.S. Census Bureau. (2017). Population projections. Retrieved from https://www.census.gov/programs-surveys/popproj.html Von Eiff, W. (2015). International benchmarking and best practice management: In search of health care and hospital excellence. In S. C. Buttigieg, C. Rathert, & W. Von Eiff (Eds.), International best practices in health care management (pp. 223–252). Bingley, England: Emerald Group. Williamson, H. J., Perkins, E. A., Fitzgerald, M., Acosta, A., Agrawal, J., & Massey, O. T. (2016). Family caregivers of individuals with intellectual and developmental disabilities: Experiences with Medicaid managed care long-term services and supports in the United States. Journal of Policy and Practice in Intellectual Disabilities, 13, 287–296. https://doi.org/10.1111/jppi.12198 Yousey, J. R., Kroll, C., Richmond, T., & Kurfuerst, S. (2012). Managing and embracing change: Recommended resources. Administration and Management Special Interest Section Quarterly, 28(3), 1–3. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Cultivating a Positive and Collaborative Workplace CHAPTER Winnie Dunn, PhD, OTR, FAOTA; Timothy J. Wolf, OTD, PhD, OTR/L, FAOTA; Evan Dean, PhD, OTR/L; and Lindsey Jarrett, PhD 15 LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ Identify the characteristics of a collaborative and positive work environment, Articulate the core elements of strengths-based approaches that help cultivate a positive and collaborative workplace, Distinguish methods to operationalize strengths-based approaches in everyday work settings and activities, and Identify core elements of strengths-based leadership in action to foster positive and collaborative workplaces. KEY TERMS AND CONCEPTS • • • • • • • Coaching Collaboration Commitment Compassion Discrimination Execution Hope • • • • • • Influencing leaders Inspirational communication Leadership Mutual respect Positive psychology Relationship builders • • • • • • Stability Strategic thinkers Strengths-based approaches Strengths-based leadership Trust Vision OVERVIEW ESSENTIAL CONSIDERATIONS here are as many work environments as there are different types of leadership. Occupational therapy practitioners work in health care and education settings as well as industry and community programs. Each work environment is organized to meet its own goals; however, some positive and collaborative methods can be effective across all work environments. In recent years, a growing body of evidence indicates that strengths-based approaches are quite effective in many fields. Strengths-based approaches highlight people’s interests and talents to guide life planning, career decisions, parenting, and relationship building. When applied to leadership, these approaches provide tools for creating a healthy, vibrant work environment that take advantage of every person’s unique characteristics. In this chapter, we introduce the core features of strengths-based approaches and demonstrate how to apply them in various leadership situations. What does a collaborative workplace look like? Collaboration is a process of colleagues working together to accomplish goals. As with many important aspects of work, specific knowledge and tools foster positive work environments and invite collaboration. First, occupational therapy practitioners must embrace the idea that every person has a leader­ ship role in some aspects of everyday work. One might be the head of a team, serving people in a clinical setting; one might be the resident expert on a new evidence-based practice that needs to be deployed across settings; or one might be teaching students who aspire to become occupational therapy prac­ titioners. Leadership starts with a mindset that creates a strong basis for people to work together; that mindset frames actions supportive of others and advances goal attainment within the organization. Strengths-based approaches of leadership provide additional tools to support all team members’ potential. T Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.015 153 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Cultivating a Positive and Collaborative Workplace CHAPTER Winnie Dunn, PhD, OTR, FAOTA; Timothy J. Wolf, OTD, PhD, OTR/L, FAOTA; Evan Dean, PhD, OTR/L; and Lindsey Jarrett, PhD 15 LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ Identify the characteristics of a collaborative and positive work environment, Articulate the core elements of strengths-based approaches that help cultivate a positive and collaborative workplace, Distinguish methods to operationalize strengths-based approaches in everyday work settings and activities, and Identify core elements of strengths-based leadership in action to foster positive and collaborative workplaces. KEY TERMS AND CONCEPTS • • • • • • • Coaching Collaboration Commitment Compassion Discrimination Execution Hope • • • • • • Influencing leaders Inspirational communication Leadership Mutual respect Positive psychology Relationship builders • • • • • • Stability Strategic thinkers Strengths-based approaches Strengths-based leadership Trust Vision OVERVIEW ESSENTIAL CONSIDERATIONS here are as many work environments as there are different types of leadership. Occupational therapy practitioners work in health care and education settings as well as industry and community programs. Each work environment is organized to meet its own goals; however, some positive and collaborative methods can be effective across all work environments. In recent years, a growing body of evidence indicates that strengths-based approaches are quite effective in many fields. Strengths-based approaches highlight people’s interests and talents to guide life planning, career decisions, parenting, and relationship building. When applied to leadership, these approaches provide tools for creating a healthy, vibrant work environment that take advantage of every person’s unique characteristics. In this chapter, we introduce the core features of strengths-based approaches and demonstrate how to apply them in various leadership situations. What does a collaborative workplace look like? Collaboration is a process of colleagues working together to accomplish goals. As with many important aspects of work, specific knowledge and tools foster positive work environments and invite collaboration. First, occupational therapy practitioners must embrace the idea that every person has a leader­ ship role in some aspects of everyday work. One might be the head of a team, serving people in a clinical setting; one might be the resident expert on a new evidence-based practice that needs to be deployed across settings; or one might be teaching students who aspire to become occupational therapy prac­ titioners. Leadership starts with a mindset that creates a strong basis for people to work together; that mindset frames actions supportive of others and advances goal attainment within the organization. Strengths-based approaches of leadership provide additional tools to support all team members’ potential. T Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.015 153 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 154 SECTION II. Organizational Planning and Culture Core Components of Leadership to Create a Positive and Collaborative Workplace This chapter considers many examples of leadership, including informal structures (e.g., peers who provide guidance) as well as more traditional structures (e.g., leadership in organizations). Leadership is a skill that involves inspiration, collaboration, a shared vision, and shared decision making (O’Malley & Cebula, 2015). Professionals thrive when their leaders ■ Create safe environments, ■ Recognize that many challenges need people to think and act in new ways, ■ Create a sense of belonging, ■ Understand they do not have all of the answers, and ■ Create shared goals (Giles, 2016; Heifetz et al., 2009; O’Malley & Cebula, 2015). Many books, articles, and websites define key attributes of a leader. In the past decade, EMyth Team (2011) outlined 5 core components of leadership: 1. 2. 3. 4. 5. Vision, Discrimination, Strategic thinking, Commitment, and Inspirational communication. When leaders use these components, they create positive and collaborative work environments (Giles, 2016; Heifetz et al., 2009; O’Malley & Cebula, 2015). Vision provides a means to understand the system and imagine how the system could work better. When implementing a vision, a leader sees many opportunities that could move the team closer to the vision. Discrimination allows the leader to evaluate potential opportunities and focus on the most salient ones. After identifying the most salient opportunities, leaders consider which plans will be most effective to meet objectives (i.e., strategic thinking). Commitment is a dedication to a process or outcome and is essential to leadership because systems are complex, and therefore teams must implement plans over a long period. Finally, a leader needs to use inspirational communication to share the vision to inspire the team and stakeholders. In occupational therapy practice and education, the core components of strengths-based leadership support a positive culture and a spirit of collaboration. In sessions with clients or families, an occupational therapy practitioner can inspire clients to keep their interests in mind as they plan how they will partner with the practitioner to meet their goals. In meetings with interprofessional colleagues, an occupational therapy practitioner collaborates strategically to solve collective challenges. Strengths-based approaches are built on positive psychology principles (Seligman, 2011). Occupational therapy leaders and managers can operationalize the core competencies in everyday actions to develop a safe, creative, shared structure of goals and actions. For example, the leader might provide readings that illustrate new ways to think creatively and solve problems in a new way. The leader establishes clear expectations about judgment-free communication that invites team members to try new ideas without fear of punishment if the idea does not work. The leader blends the authority over an area of work with the responsibility to operate independently to create solutions. The leader creates structures such as regular supervision and coaching sessions so team members can get support when they need it. Operationalized procedures, such as incorpo­ rating brainstorming sessions that accept all ideas before actual planning begins, also communicate the values of acceptance of others’ ideas within the team. When teams value a strengths-based perspective, a new team member might notice procedures that empower the team to test new ideas. Areas of Strength-Based Leadership Strengths-based approaches to leadership cultivate positive and collaborative workplaces. The Gallup Corporation has researched strengths and leadership for many decades. Based on more than 20,000 interviews and 10,000 surveys, Gallup asked people why they followed the most influential leaders in their lives. Synthesizing the Gallup results, Rath and Conchie (2008) found 3 key areas. The most effective leaders 1. Invest in strengths (e.g., provide professional development based on a member’s strengths, assign tasks based on each team member’s strengths), 2. Surround themselves with diverse team members (e.g., people with different skill sets, varying backgrounds, different professional training), and 3. Understand their followers’ needs (e.g., learning and supporting followers’ goals, guiding development of new skill sets in followers; Rath & Conchie, 2008). When leaders look for and foster the strengths of others, group members are more engaged in their work, more productive in service to the team’s goals and outcomes, and less likely to quit their job (Rath & Conchie, 2008). No single person in a group has to have all the skills needed to accomplish the group’s collective goals; knowing everyone’s strengths provides a way to leverage everyone’s talents, which creates more capacity. Another factor that emerges from exploration of strengths-based leadership is the leader gets to know what group members need to be productive and satisfied. Feeling heard engenders loyalty. Leader strengths Rath and Conchie (2008) described the actions of leaders who cultivate positive workplaces. Some leaders are great at execution; they know how to implement plans and persist to meet goals. Influencing leaders are focused on a wider audience and look for opportunities to align groups with common interests. Other leaders are relationship builders; they see how group members might connect to each other and create outcomes that are greater than the individuals might produce individually. Finally, some leaders are strategic thinkers; they Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 15. Cultivating a Positive and Collaborative Workplace see connections among ideas to create inspiring opportunities. These areas of strengths-based leadership are consistent with the core components outlined earlier in the chapter (i.e., vision, discrimination, strategic thinking, commitment, inspirational communication; EMyth Team, 2011). No one leader can have all these characteristics; skillful strengths-based leaders have insight about their own strengths and recognize other characteristics in team members. This approach enables everyone to be a “leader” within the group, because each person’s way of approaching a solution is uniquely theirs to contribute to the collaborative workplace. Follower needs What inspires followers to connect to a leader’s vision? Followers need specific things from their leaders to feel cared for, maintain loyalty, and be productive members of a group. According to findings from Gallup’s research (see Rath & Conchie, 2008), followers need 4 things from their leaders: 1. 2. 3. 4. Trust, Compassion, Stability, and Hope. Trust is a belief that one can rely on what is happening and is at the foundation of a healthy workplace. Some organizations talk about honesty and integrity, which are also bound to a trustworthy culture. Trust develops across time and is fostered when a leader is both transparent and authentic. In trusting work environments, everyone is more engaged and efficient, knowing that team members will follow through to accomplish collective goals. Compassion is a feeling of empathy for others and is an indicator that the leader cares about the people in the organization. When people feel cared for, they are more loyal and engaged with the work of goal attainment. Compassion also relates to people wanting the leader to create a positive environment that inspires them. People want a sense of stability from their leadership. Stability is a sense that a person can count on the steadiness of the organization as a whole or within a team. When people worry about being paid, having a job, or feel unwilling to share a divergent idea on their team, their worry diverts energy from the work. Being transparent about goals and finances is a clear way to demonstrate the organization’s status and makes people feel secure. Finally, followers need to feel hope about the future. In the workplace hope involves feeling enthusiastic about the future; followers who feel hopeful are highly engaged at work, whereas people who did not feel enthusiastic are disengaged from their work (Rath & Conchie, 2008). Hope is especially important during uncertain times or in chaotic circumstances. People want to see a way through the challenging times to better outcomes. Sending a message of hope involves being proactive (e.g., initiating plans and ideas for expansion) rather than reactive (e.g., only responding to situations as they occur—putting out fires). 155 Review Questions 1. How does developing a vision enable the occupational therapy manager to formulate a plan for developing positive communications? 2. How does leadership view the strengths-based approach? 3. Describe the needs of followers. PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Application of Strengths-Based Leadership in Community Settings Consider the following example of applying strengths-based leadership in a community setting. Addie is an occupational therapy manager who leads a team of early intervention providers serving families with children with developmental disabilities. Taking a strengths-based approach, Addie believes that parents know how to best parent their child and uses a coaching framework with families to (1) empower the family to create solutions and (2) communicate a relationship based on mutual trust. Addie also believes that the child will thrive when the family has the knowledge needed to incorporate the child into family routines. Addie uses coaching to support family members to develop solutions to their challenges with their child. Additionally, Addie and her team write evaluations in family-friendly language (e.g., saying the child’s name instead of “patient” or “child”; not using jargon) that acknowledge the strengths of the child and family as well as daily life challenges indicated by families (for a specific example of coaching in action, see Augustyn & Wallisch, 2017). Addie also uses the same approach when working with colleagues. When a colleague comes to Addie with a challenging situation, Addie asks reflective questions to both understand the parameters of the situation’s challenges and help the colleague think deeper about how to craft a satisfying outcome. For example, Grif, a new occupational therapy practitioner, came to Addie about a family he was serving. The child was exhibiting behavioral patterns consistent with a person who is a sensory seeker (i.e., needs a lot of movement and stimulation), which was causing challenges with family routines because the parent was a sensor (i.e., prefers little sensory input). The family’s main challenge was the after-school routine at the end of the school and workday. The parent needed a quiet, calm atmosphere to settle in after a day at work; the child, however, wanted to interact with the parent and needed to move around and make noise because she had to control her movements at school. This difference in sensory patterns usually led to an argument between the parent and child. In each visit with the family, Grif suggested many strategies in which the child could get the movement she needed, but the family did not use the strategies in the family routine. Grif was frustrated and asked Addie for suggestions on how to move forward with the family. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 156 SECTION II. Organizational Planning and Culture When Grif approached Addie for advice, Addie began by asking questions to fully understand the current situation, such as ■ “What have you tried that worked?” ■ “Why do you think the suggestions have not worked?” ■ “I wonder if the parents know enough about the child and ■ parent’s sensory pattern differences to understand why you’re making your suggestions?” and “How could you involve the family in developing an approach that would work for them?” Addie also shared a story from her past when she had difficulty getting parent buy-in until she began asking questions and the family members developed strategies that fit with their routines. Grif creates a new plan to incorporate sensory processing ideas into his discussions with the parent by asking coaching questions. For example, Grif could ask, “What does your daughter seem to need when she gets home?” to foster discussion about the child’s need for movement. Following up could be questions such as “How could your daughter get movement in a way that doesn’t bother you?” or “What are some times your daughter gets movement, and it has been OK for you?” In this example, Addie executed a coaching conversation that Grif could then use with the family. The conversation was solution focused; Addie supports Grif in considering what worked in the past, how to apply those ideas to the current situation, and how to create a new strategy. Addie may offer insight based on experience but mainly helps Grif think through possible solutions. A key piece of this relationship is that Addie does not judge Grif ’s actions or ideas. If the solution does not yield desired outcomes, Addie helps explore why the solution did not work and seeks to define a new solution with Grif. Addie knows that building a nonjudgmental environment in which people are empowered to find their own solutions builds a culture of trust, compassion, and stability for families and colleagues. Application of Strengths-Based Leadership in Research and Industry Lindsey, an occupational therapy manager, is leading a quality assurance research project at a large hospital system. The intention of the project is to examine the most appropriate venue of care for people leaving the hospital. Using a strengths-based approach, Lindsey knows that the clinicians who provide care to the patients in the hospital will know the factors crucial to discharging people appropriately from the hospital. Since occupational therapy practitioners are trained to interact, collaborate, advocate, and negotiate with other health care professionals (Brown et al., 2015), Lindsey decides to use coaching techniques, as well as qualitative research methods, to ■ Identify the barriers to safe and effective discharge planning, ■ Develop an understanding of the discharge planning process, ■ Identify goals of the clinicians, and ■ Assess expectations for research and development. Occupational therapy practitioners add value to the research process as they actively think critically and solve problems across diverse situations in the health care continuum. Lindsey knows that clearly defined goals, mutually derived expectations, and outcomes-centered planning are crucial for producing evidence-based research and ultimately more effective practices. As the research project progresses from design to implementation, Lindsey consistently creates opportunities for feedback with colleagues, clinicians, and study participants, as well as conducts analyses that provide the hospital system with outcomes and actions derived from evidence. Lindsey is a strategic thinker; she sees the connections across the stakeholders involved in discharge planning and recognizes how to create opportunities for both growth and effectiveness. In addition, Lindsey has strengths as an executor by deriving clear goals and expectations in the research process that will also have implications for practices in this hospital system. Review Questions 1. Describe the coaching relationship with families. 2. What are some questions the occupational therapy practitioner can ask the parents of a child who is having challenges to get at a workable plan or solution? 3. Identify the characteristics of a strategic thinker and an executor. SUMMARY Strengths-based leadership requires a lot from everyone on the team. There is a focus on everyone’s assets to build a plan for achieving goals, so all members have some responsibility for the work. Creating a safe work environment for exploration and creativity fosters new ideas and supports team members as they explore options. Strengths-based leadership is built on trust and compassion, with a sense of adventure about finding new ways to be successful. ❖ LEARNING ACTIVITIES 1. Consider your own strengths. The book Strengthsfinder 2.0 (Rath, 2007) provides a link to an online test to find your top 5 strengths. How have you used these strengths in the past? How might you use these strengths in an occupational therapy context? 2. Discuss a time when you did not feel safe to bring up new ideas. What behaviors and contexts alerted you to the risk? What would you do now to reduce those fears and act with compassion? 3. What have you observed an occupational therapy practitioner do to foster trust and compassion when developing a relationship with a family under her or his care? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 15. Cultivating a Positive and Collaborative Workplace 157 CASE EXAMPLE 15.1. Strengths-Based Leadership in Fieldwork Supervision Students entering a fieldwork setting come with a variety of strengths and interests. At the same time, students must develop specific competencies related to occupational therapy practice. It can be difficult to balance the strengths and interests of the student with the competencies that need to be developed. This case describes how a strengths-based leader supervising fieldwork students approaches this challenge in a community setting serving adults with intellectual disability. Joseph, the fieldwork coordinator, begins by creating a culture of mutual respect. When introducing the people served at the site, Joseph introduces them by their names and speaks of their interests and strengths instead of the support needs for everyday life. He encourages fieldwork students to think of the people they serve as they would any other adult. “Adults with intellectual disability should have the opportunity to live lives like anyone else, and our job is to support them in doing that,” he would say. In supervision meetings, Joseph communicates trust and stability by establishing a safe learning environment. He does this by encouraging the students to think deeply about the challenges they encounter and think through possible solutions. As students try their ideas, Joseph would ask, “What kept this from working? What could you change? What insights do you have?” To model the safe environment, Joseph asks students to help to think through practice-related challenges he is facing. During interactions with students, Joseph is quick to point out areas of strength and encourages the students to apply their strengths to the practice. For example, when a student displayed aptitude for organization and communicating with others (the influencing strength in leadership), Joseph approached her about creating a training for riding the bus, which involved collaboration with a local transportation agency and close communication with families. While the student was using her strengths of organizing and communicating, she was also gaining experience with assessment to determine what individual support a client might need and intervention to consider when a person might need accommodations. In another example, when a student expressed an interest in cooking, Joseph asked the student to work with an individual who needed to build his cooking skills to achieve his goal of working in a restaurant (using the student’s execution strength). Joseph could facilitate these pairings because he knew people’s interests and strengths. Because Joseph is committed to developing student strengths, he learns to incorporate the strengths and interests while also ensuring they build the essential practice-related competencies. CASE EXAMPLE 15.2. Strengths-Based Leadership in a Research Team Eva is a doctorally prepared occupational therapy practitioner who leads a research group of interdisciplinary team members within a health care business that is focused on improving health care outcomes by providing quality care at the lowest cost. The team is responsible for creating innovative health care solutions from data insights (called edge development in the industry). Eva’s team consists of clinicians, data scientists, analysts, and other PhD-level researchers, all trained from various sectors of the health care industry. As the leader, Eva uses coaching techniques in every interaction with the team to (1) understand the individual goals of each person, (2) evaluate the strengths and skills of each team member, and (3) strategically evaluate opportunities for collaboration and connection across the team. These interactions afford Eva the opportunity to harness the highest quality work based on the strengths of each team member. Eva knows from her professional training in occupational therapy and her postprofessional training in science that effective research and development relies on collaboration among those with various skills and abilities. This knowledge is at the forefront of every research plan, analysis, and report. For example, team members who are best at executing serve as leaders in collecting the information and organizing; those best at influencing serve as leaders in getting the messages about their findings to others. In this way, Eva cultivated a research environment, and her team members grew as leaders in industry while contributing to current work. Eva is focused on relationship building because she sees how the team can connect with each other and create outcomes that are collaboratively driven. She instills trust and compassion with the team, which allows the team to feel cared for and engaged in her vision and the work for the health care industry. CASE EXAMPLE 15.3. Strengths-Based Leadership in an Academic Department Jamie is a new department chair starting in a program that has been in existence for some time. The department has gone through a long period of transition during which no one was in the chair position full-time for multiple years. Using a strengths-based approach, Jamie knows that to get the team working together, everyone needs to collectively develop a mission, vision, and strategic plan for how they see the department developing into the future. Jamie uses coaching techniques to help the team develop action plans around long-term strategic goals. Part of this process is working together to match individual strengths and interests to action plans in the overall strategic plan. The team’s strategic plan becomes the basis for all activities in the department. There is a clear division of labor for who will champion the different components of the action plan based on faculty strengths. Every faculty member’s effort is allocated based on what that faculty member is responsible for in the strategic plan each year; Jamie and each faculty member build professional development plans to reflect these responsibilities. In an academic environment, expectations, resources, and leadership can change rapidly and often have a direct impact on the department’s actions. These changes can come from the university itself (e.g., new senior leadership enacts a new strategic plan), from an accreditation body (e.g., Accreditation Council for Occupational Therapy Education® [ACOTE]) changes academic standards), or even from the health care industry (e.g., Medicare changes reimbursement guidelines that affect occupational therapy). Jamie empathizes with the team when plans change that are out of the team’s control; however, Jamie also consistently works to maintain the department’s focus; the team directs efforts toward areas within the department’s control to achieve collective goals with the university. Annually, the team revisits the strategic plan to reflect on progress and modify action plans based on changes that have occurred over the past year. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] (Continued) 158 SECTION II. Organizational Planning and Culture CASE EXAMPLE 15.3. Strengths-Based Leadership in an Academic Department (Cont.) Jamie is a strategic thinker and keeps the team collectively focused on long-term goals. Developing action plans for each faculty member that utilize each faculty member’s unique strengths toward the collective goal helps build trust within the department. The team learns to rely on each other for meeting individual and collective goals. Jamie is also influencing the team to recognize how everyone’s actions can affect not only the university but also the community and the profession. By consistently using the faculty’s action plan to establish annual goals and allocate effort, Jamie is also providing stability by setting clear expectations for all faculty to follow. Finally, and most important, Jamie is projecting hope to the team. It is very easy in an academic environment to develop an external locus of control and focus on reacting to what is happening; however, establishing a clear and collective mission and vision, establishing a strategic plan for how to achieve the mission and vision, and focusing on the action steps necessary to work toward these goals all contribute to the faculty feeling hopeful about where they are headed and that they can influence their own future. Review Questions 1. 2. 3. What do the 2 applications and 3 case examples have in common? With which behaviors do you identify? How can you foster those behaviors in your own practice? How might being an “executing” leader create challenges for a team? What could the team do to create a better sequence of work activities? How might you best utilize an “influencer” occupational therapy practitioner in your practice? ACOTE STANDARDS This chapter addresses the following ACOTE Standard: B.4.24. Effective Intraprofessional Collaboration. REFERENCES Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi .org/10.5014/ajot.2018.72S217 Augustyn, J., & Wallisch, A. (2017). Occupational therapy in early intervention: Supporting families and children through cultural competency and coaching. OT Practice, 22(6), 14–17. Brown, T., Crabtree, J. L., Mu, K., & Wells, J. (2015). The next paradigm shift in occupational therapy education: The move to the entry-level clinical doctorate. American Journal of Occupational Therapy, 69(Suppl. 2), 1–6. https://doi.org/10.5014 /ajot.2015.016527 EMyth Team. (2011, January 12). The five core leadership skills [blog post]. Retrieved from http://blog.emyth.com/the-five-core -leadership-skills Giles, S. (2016, March 15). The most important leadership competencies, according to leaders around the world. Harvard Business Review. Retrieved from https://hbr.org/2016/03/the-most -important-leadership-competencies-according-to-leaders -around-the-world Heifetz, R. A., Grashow, A., & Linsky, M. (2009). The practice of adaptive leadership: Tools and tactics for changing your organization and the world. Boston: Harvard Business Press. O’Malley, E., & Cebula, A. (2015). Your leadership edge: Lead anytime, anywhere. Wichita, KS: KLC Press. Rath, T. (2007). StrengthsFinder 2.0. New York: Simon & Schuster. Rath, T., & Conchie, B. (2008). Strengths based leadership: Great leaders, teams, and why people follow. New York: Simon & Schuster. Seligman, M. (2011). Flourish. New York: Free Press. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Promoting and Managing Diversity 16 Roxie M. Black, PhD, OTR, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ Understand and accept the need for promoting and managing diversity; Identify the types of diversity in the workplace; Begin an assessment of current diversity issues and needs in their programs, departments, and organizations; Reflect on their own cultural competency and effectiveness; and Use resources to develop a diversity training program. KEY TERMS AND CONCEPTS • • • • • • Controlling Cultural assessment Cultural competence Cultural effectiveness Directing Diversity • • • • • • Educating about diversity Health disparities Health equity Ongoing education Organizing Planning • • • • • Promotion of diversity Reflective discussion Self-awareness Staffing Valuing and maintaining diversity OVERVIEW ESSENTIAL CONSIDERATIONS hen examining or even perusing the multiple chapters in this text, readers recognize that managing an occupational therapy program or department is complex, requiring occupational therapy managers to be highly skilled and effective in accomplishing many roles, responsibilities, and requirements. Those requirements, according to Braveman (2014), are context dependent, and the role and expectations of occupational therapy managers may require flexibility within each setting. Given the complexity within changing contexts, how does one also promote and manage diversity within each occupational therapy program and department? Yet given the increasing plurality in the United States and beyond, we must! This chapter provides theoretical background information and pragmatic guidelines to assist occupational therapy managers in promoting and managing diversity in the occupational therapy clinic and beyond. Diversity Today W The definition of diversity has changed over the years. Initially, people thought of only racial and ethnic diversity (and many continue to hold this notion). Black (2002) defined diversity as also “incorporating gender, age, ability, sexual orientation, and class” (p. 140). Although expanded beyond race and ethnicity, this definition is still far too narrow. Currently, the concept of diversity is more inclusive, identifying “life experiences, lifestyle choices and ideas, such as socioeconomic status and sexual orientation [as well as] the social determinants of health” (Becker’s Hospital Review, 2016, para. 2). Other scholars and authors have added the concepts of religious beliefs, political beliefs, and other ideologies (Volckmann, 2012). When considering diversity’s many aspects, any interaction might be considered cross-cultural. The Pew Research Center (2015) reported that U.S. population statistics (see Table 16.1) indicate that there is more Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.016 159 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Promoting and Managing Diversity 16 Roxie M. Black, PhD, OTR, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ Understand and accept the need for promoting and managing diversity; Identify the types of diversity in the workplace; Begin an assessment of current diversity issues and needs in their programs, departments, and organizations; Reflect on their own cultural competency and effectiveness; and Use resources to develop a diversity training program. KEY TERMS AND CONCEPTS • • • • • • Controlling Cultural assessment Cultural competence Cultural effectiveness Directing Diversity • • • • • • Educating about diversity Health disparities Health equity Ongoing education Organizing Planning • • • • • Promotion of diversity Reflective discussion Self-awareness Staffing Valuing and maintaining diversity OVERVIEW ESSENTIAL CONSIDERATIONS hen examining or even perusing the multiple chapters in this text, readers recognize that managing an occupational therapy program or department is complex, requiring occupational therapy managers to be highly skilled and effective in accomplishing many roles, responsibilities, and requirements. Those requirements, according to Braveman (2014), are context dependent, and the role and expectations of occupational therapy managers may require flexibility within each setting. Given the complexity within changing contexts, how does one also promote and manage diversity within each occupational therapy program and department? Yet given the increasing plurality in the United States and beyond, we must! This chapter provides theoretical background information and pragmatic guidelines to assist occupational therapy managers in promoting and managing diversity in the occupational therapy clinic and beyond. Diversity Today W The definition of diversity has changed over the years. Initially, people thought of only racial and ethnic diversity (and many continue to hold this notion). Black (2002) defined diversity as also “incorporating gender, age, ability, sexual orientation, and class” (p. 140). Although expanded beyond race and ethnicity, this definition is still far too narrow. Currently, the concept of diversity is more inclusive, identifying “life experiences, lifestyle choices and ideas, such as socioeconomic status and sexual orientation [as well as] the social determinants of health” (Becker’s Hospital Review, 2016, para. 2). Other scholars and authors have added the concepts of religious beliefs, political beliefs, and other ideologies (Volckmann, 2012). When considering diversity’s many aspects, any interaction might be considered cross-cultural. The Pew Research Center (2015) reported that U.S. population statistics (see Table 16.1) indicate that there is more Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.016 159 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 160 SECTION II. Organizational Planning and Culture TABLE 16.1. Racial Demographic Trends in the United States, 1975–2065 by Percentage of Population YEAR WHITE BLACK HISPANIC ASIAN 2065 (projected) 46% 13% 24% 10% 2035 (projected) 57% 13% 22% 8% 2005 64% 13% 18% 6% 1985 76% 12% 8% 3% 1965 80% 12% 5% 2% Source. Adapted from Cohn & Caumont (2016). Cultural competence Cultural competence has been defined in multiple ways. AOTA (2018) described it as “the process of actively developing and practicing appropriate, relevant, and sensitive strategies and skills in interacting with culturally different persons” (p. 2). In a more comprehensive and commonly used definition that focuses on client care, Camphina-Bacote (1999, as cited in Rodakowski & Suarez-Balcazar, 2016) suggested that cultural competence is displayed when a practitioner ■ “Recognizes differences in culturally determined health beliefs and behaviors, ■ Respects variations that occur within and among cultural ethnic and racial diversity now than in the past, and driven by recent and projected immigration, such pluralism will continue to increase (Cohn & Caumont, 2016). Yet, despite these statistics, most occupational therapy practitioners and managers are White (90.9%) and female (85.3%; American Occupational Therapy Association [AOTA], 2015). Sullivan and Mittman (2010) argued, “Access to a health professions career should be available to all, not only because of issues of equity and social justice but because without such diversity, we as a nation will not benefit for developing the talent, creativity, and potential of the human capital that exist in all segments of our society” (p. 252). Regardless of one’s own cultural background, the likelihood of working with someone who is culturally different from oneself, whether a supervisor, coworker, staff member, or client or patient, is high. Mor Barak (2017) identified 3 impetuses for managers to consider and plan for diversity within their programs or departments: 1. Diversity is a reality that is here to stay, 2. Diversity management is the right thing to do, and 3. Diversity makes good business sense (p. 219). Weech-Maldonado et al. (2002) suggested that the goal of managing diversity “is to enhance workforce and customer satisfaction, to improve communication among members of the workforce, and to further improve organizational performance” (p. 111). Therefore, managing diversity is an important aspect of the occupational therapy manager’s role and responsibilities. Culturally Effective Management The majority of today’s health care organizations expect their leaders to “help manage a new era of culturally competent, patient-centered care that reduces health and healthcare disparities” (Dotson & Nuru-Jeter, 2012, p. 35). However, many scholars believe that there is a lack of culturally competent and culturally effective care practiced in many health care departments (Aries, 2004; Dreachslin, 2007; Weech-Maldonado et al., 2002). Others believe that diversity management itself can lead to a culturally competent organization (Betancourt, 2006, as cited in Dotson & Nuru-Jeter, 2012). groups, and ■ Alters practice to provide effective services for clients from diverse backgrounds” (p. 414). Cultural competence requires occupational therapy practitioners to be culturally aware of themselves and others, to be knowledgeable about their clients’ culture and beliefs and the sociopolitical systems within the dominant culture, and to be skilled communicators in cross-cultural interactions. Self-awareness is crucial to such cultural awareness. Self-awareness is “the recognition a person has of being a unique person with specific background that influences his or her beliefs, values, attitudes and behaviors” (Black, 2016c, pp. 83–84). Dreachslin (2007) argued, “Self-awareness is the most powerful tool a health care leader has in managing diversity” (p. 82), and that notion has been supported by others (e.g., Black, 2016a). Cultural effectiveness includes all of the aforementioned aspects of cultural competence, coupled with an opportunity for several cross-cultural interactions with significant reflection during and following the interactions (Wells et al., 2016). Occupational therapy practitioners who are attempting to become more culturally competent are more effective if the organization in which they work is considered a culturally competent organization. To become a culturally competent health care organization, the leadership must understand the local community and the role of the organization within the community (HRET, 2013). Steps to move toward cultural competence include doing a community survey, sharing the results of the survey with the community, and educating staff about the needs of the diverse people within the community. Although there is significant occupational therapy literature about cultural competency (Black & Wells, 2007; Bonder & Martin, 2013; Gupta, 2008; Suarez-Balcazar et al., 2009) and cultural effectiveness in occupational therapy practice (Wells et al., 2016), little research exists about how to be a culturally effective occupational therapy manager. However, research and literature published outside the occupational therapy field has shown that effectively dealing with diverse issues within one’s department and organization has positive results on productivity (Saxena, 2014), finances (Weech-­ Maldonado et al., 2002), and diminished health disparities for the underserved (Betancourt et al., 2003). Other scholars cite some of the difficulties inherent in developing a culturally competent department, reporting that managing diversity is hard work. Parker (2015) stated, Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 16. Promoting and Managing Diversity “[M]anaging differences requires energy, commitment, tolerance, and . . . appreciation among all members involved. . . . Learning to manage and ultimately appreciate differences requires learning, emotional growth, and stretches the boundaries of all participants” (p. 38). Health disparities Many believe that cultural competence affects health dispar­ ities. Health disparities are defined by Smith (2011) as “dif­ ference in the quality of health care related to race or ethnicity, gender, education or income, disability, geographic location, or sexual orientation that is not due to access-related factors or clinical needs” (p. 547). Despite continued work on diminishing health disparities during the last several years, reports by the National Center for Health Statistics (NCHS; 2017) indicate that only minimal changes have occurred. A U.S. government report on racial and ethnic disparities states that Despite improvements over time in many of the health measures presented in this Special Feature, disparities by race and ethnicity were found in the most recent year for all 10 measures, indicating that although progress has been made in the 30 years since the Heckler Report, elimination of disparities in health and access to health care has yet to be achieved. (NCHS, 2016, p. 21). Dotson and Nuru-Jeter (2012) believe that “the presence of health and health care disparities indicates, in part, the lack of a culturally competent care perspective at the management level” (p. 38). Health Equity and Enhanced National CLAS Standards Health equity “is the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities” (Healthy People 2020, 2014, para. 5). The current cost of health disparities is estimated to be $230 billion (Riley, 2016). To enhance health equity for all, the United States developed national standards to help guide and improve an organization’s ability to address health care disparities. These National Standards for Culturally and Linguistically Appropriate Services (CLAS) have been developed to implement Culturally and Linguistically Appropriate Services to all clients and patients (see Exhibit 16.1). Review Questions 1. Given the information above, how culturally effective do you consider yourself to be as a practitioner, student, or researcher? 2. How would you describe your organization’s effectiveness in promoting diversity? 3. What is the relationship between cultural competence and health disparities? 161 EXHIBIT 16.1. National CLAS Standards in Health and Health Care The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations to: Principal Standard: 1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Governance, Leadership, and Workforce: 2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources. 3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area. 4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. Communication and Language Assistance: 5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. Engagement, Continuous Improvement, and Accountability: 9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations. 10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. 15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public. Source. The National CLAS Standards, by U.S. Department of Health and Human Services, Office of Minority Health (n.d.). In the public domain. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 162 SECTION II. Organizational Planning and Culture PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY For many reasons cited earlier, managing diversity must be a goal of all occupational therapy managers. This might feel overwhelming to some managers, particularly those who are new to a position and who may wonder how these goals can be translated and incorporated into particular tasks and duties of the role. Braveman (2014) identified 4 major functions of management: 1. 2. 3. 4. Planning, Organizing and staffing, Directing, and Controlling (p. 1019). To organize and simplify the complexities of managing diversity, this section focuses on how managing diversity can happen within these 4 areas of management function (see Table 16.2). Planning Planning is the first step in diversity management for the occupational therapy manager and includes revising the strategic plan, writing goals, developing timelines for training, and thinking about hiring objectives. The function of planning may be considered the highest level of management because of its top-down nature. Decades of laws and regulations supporting the rights of all people and therefore fostering inclusion, such as the Civil Rights Act of 1964 (P. L. 88–352), the Heckler report of 1985 (Heckler, 1985), and the Healthy People Initiative of 2010 (NCHS, 2010), have shifted the societal stance on inclusivity. As a result, most health organizations now recognize the importance of having a diverse workforce, particularly to reflect the population of the larger community. Therefore, the questions a manager and his or her organization must ask are no longer should I plan for diversity or why must I plan for diversity but rather how do I manage diversity issues in my program and organization? Planning involves the promotion of diversity. This includes being clear about the values and goals of the organization and how promoting diversity within one’s program or department can help achieve those goals. Mission, vision, and value statements must reflect the promotion of diversity (see Exhibit 16.2), and the strategic plan must incorporate goals to achieve these tasks. However, although a diverse workforce often brings a diversity of thoughts, ideas, perspectives, and practices, which may increase an organization’s competitiveness, promoting diversity may be difficult. Volckmann (2012) stated that “promoting diversity within organizations has been a task, a challenge to be met in the name of values of equity and social justice, as well as an economic necessity” (p. 2). Another aspect of planning is to create and implement the department budget (Braveman, 2014). Within a culturally competent occupational therapy department, the manager must include the need for funding for diversity. This may include a wider search for new positions for diverse occupational therapy staff, trainings that may include bringing in guest speakers or purchasing videos and other technology, or visits to other occupational therapy departments in the area that have more experience or skills in building an inclusive and diverse group of people. The budget may also include increased signage in multiple languages and the hiring of translators or cultural brokers. In other words, the department must put money where its mouth is. If occupational therapy managers are serious about developing a culturally competent program, they must develop a budget to support it, which is not an easy task given the current financial stressors on health care organizations. TABLE 16.2. Cultural Functions of Managers MANAGEMENT FUNCTIONS (BRAVEMAN, 2011) CULTURAL FUNCTIONS Planning Promoting of diversity ■ Developing mission, vision, and value statements that reflect the promotion of diversity. ■ Creating goals in the strategic plan to achieve the tasks above. ■ Budgeting to fund diversity. ■ Creating signage in multiple languages. Organizing and staffing Achieving diversity ■ Reviewing and developing cultural self-awareness. ■ Hiring diverse staff and leadership. Directing Educating for diversity ■ Becoming culturally competent, starting with one’s own cultural self-awareness. ■ Mentoring, coaching, and training staff. ■ Committing to ongoing education. ■ Practicing reflection on training and cross-cultural interactions. Controlling Valuing and sustaining diversity ■ Implementing and tracking of continuous quality improvement. ■ Developing performance measures for department functions. ■ Researching and publishing results of above. CULTURAL TASKS Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 16. Promoting and Managing Diversity EXHIBIT 16.2. Example of an Organization’s Value Statement At MaineHealth, our values are at the very core of living our mission and vision of working together so our communities are the healthiest in America. Wherever and whenever you interact with us, you can expect our team members to embody the following values in action: Patient Centered: We focus on each individual’s unique needs, and partner with the people we care for, their families, and care teams to develop a shared plan. ■ Act with compassion and kindness. ■ Listen actively and validate concerns; focus on the individual’s needs. ■ Communicate effectively with patients, clients, and families. ■ Treat everyone with respect and courtesy; acknowledge cultural differences. ■ Be empowered to advocate and speak up for patient and client safety. ■ Partner with the people we care for, their families, and care teams to develop a shared plan. Respect: We embrace diversity and recognize the value of each person. ■ Recognize all the people we care for, their family, visitors, and coworkers as valued members of the health care team. ■ Listen actively and respond thoughtfully. ■ Treat others as you would want to be treated. ■ Embrace diversity, acknowledging each person’s uniqueness. ■ Be empathetic, compassionate, and kind. ■ Foster a professional and healing atmosphere. Integrity: We are honest, transparent, and ethical and maintain a culture of trust and accountability ■ Demonstrate professionalism at all times, regardless of the behavior of others. ■ Maintain confidentiality and respect the privacy of all. ■ Develop and maintain a culture of trust and accountability. ■ Act with honesty and transparency at all levels of the organization. ■ Model behavior that is consistently honest and ethical. ■ Acknowledge mistakes as opportunities to learn and grow. Excellence: We set high standards and always strive to exceed expectations. ■ Consistently seek improvements in processes and performance. ■ Set high standards. ■ Strive to exceed expectations with every interaction. ■ Lead by example. ■ Work collaboratively as a team. ■ Pursue opportunities to learn and grow personally and professionally. Innovation: We welcome diverse perspectives, embrace change, and are committed to lifelong learning. ■ Welcome change with a positive attitude. ■ Inspire others and foster creativity. ■ Be courageous. ■ Encourage diverse perspectives. ■ Invest in people, technology, and research. ■ Commit to lifelong learning and educating. Source. Our Values, by MaineHealth (n.d.). Copyright © 2019 by MaineHealth. Available at https://mainehealth.org/about/our-values 163 Organizing and Staffing Organizing and staffing are how managers hire new staff or reassign duties of current staff to align and organize their departments to support the goals of the larger organization and to promote diversity. Promoting diversity within one’s workplace can be achieved by the way in which occupational therapy managers consider and apply Braveman’s (2014) second management function. Skillfully integrating these 2 tasks helps achieve diversity. Research indicates that hiring racially diverse leadership is important in developing a diverse workforce (HRET, 2011; Jayne & Dipboye, 2004). Yet, even though Aries (2004) reported over a decade ago that most managers were consciously hiring a more diverse staff, a 2015 survey found that racial/ethnic minorities still constitute only 14% of hospital board members, 12% of executive leadership positions, and 17% of first- and mid-level management positions (Becker’s Hospital Review, 2016). However, given the limited numbers of occupational therapy practitioners in the United States who are ethnically diverse (AOTA, 2015), where do managers find them? Remember that diversity covers a wide array of differences (see “Diversity Today” above). One might seek out people from another part of the country, someone with age differences, sexual orientation or sexual identity differences, religious or political differences from the mainstream, and more. The bottom line here, summarized by Dotson and Nuru-Jeter (2012), is “a culturally competent care organization is needed; so is a diverse workforce to operate it” (p. 8). Directing Directing includes mentoring, coaching, and staff training in this area of management, (Braveman, 2014), all of which are addressed here under the term educating about diversity. This is a vital, yet often overlooked, inexpertly planned, and poorly accomplished task of occupational therapy managers. If the goal is to lessen health disparities and develop a culturally competent occupational therapy program or department, Dotson and Nuru-Jeter (2012) argued that “a culturally competent care perspective [must be evident] at the management level” (p. 41). It must start at the top. Therefore, it is important for each occupational therapy manager to be culturally competent. There is considerable occupational therapy and other health care literature about how individuals may develop cultural competence (Black, 2016b; Bonder & Martin, 2013; Gardenswartz & Rowe, 2010; Wells et al., 2016), and there are multiple ways and programs to help people become more knowledgeable about diversity issues, sensitive to the nuances that are part of cross-cultural interactions, and skilled in communication with others. The first (and perhaps the most important) aspect to consider in any training is developing self-awareness. Other areas that diversity training must include are being knowledgeable about clients’ varied cultures and how to develop culturally interactive skills. To be effective managers and practitioners, this work must be infused with self-reflection during and following each interaction while considering the context within which the context occurs. (For more information, review the model for culturally effective care in Wells et al., 2016.) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 164 SECTION II. Organizational Planning and Culture In 2013, the American Hospital Association published a document that focused on how to develop a culturally competent health care organization and suggested that a successful educational program includes these 4 steps: help new staff members catch up with the others regarding knowledge and skills and evaluate ongoing development of staff, which will guide further training. 1. 2. 3. 4. Controlling Cultural assessment, Multiple training methods, Ongoing education, and Measurement and tracking (HRET, 2013). Cultural assessment Cultural assessment includes conducting an evaluation of the staff’s knowledge of cultural competence, and then using the data from that assessment to examine the working relationship between staff and diverse clients and the impact on clinical encounters. Multiple training methods Multiple training methods could include conducting a case study review, having observations of live interactions with clients followed by reflective discussions, and using online education and orientation programs (HRET, 2013). Reflective discussion is what Schon (1983) describes as “reflection on action,” which follows any interaction to judge “how successfully you were and whether any changes to what you did could have resulted in different outcomes” (Wells et al., 2016, p. 76). Some training programs are ineffective and, if handled poorly, can result in substantial backlash (Pitts, 2005). Von Bergen et al. (2002) described unintended negative effects of poorly handled diversity management, which can be caused by ■ Trainer’s own psychological values are used as training templates; ■ Trainers having political agendas or supporting and promoting particular special interest groups; ■ Training is too brief, too late, or only used in response to an existing crisis situation; ■ Training is only provided as remediation and trainees are ■ ■ ■ considered people with problems, or worse, are considered to be the problem; People are forced to reveal private feelings or are subjected to uncomfortable, invasive physical and psychological exercises; Individual styles of participants are not respected; and Training is “canned,” often presented too shallowly or too deeply, ignoring the needs of the group or its members. (p. 241) Robins (2016) stated that diversity or cultural competency training “should strive to achieve a commitment to appropriate practice and policies for diverse groups of people” (p. 304). These include clients/patients, staff, and managers and other leaders of the organization. Ongoing education Ongoing education (HRET, 2013) includes scheduling continuous staff education and periodic assessments. These activities Measurement and tracking of progress coincides with Braveman’s (2014) final function of an occupational therapy manager, which he labeled controlling. The cultural function of this step is identified as valuing and maintaining diversity. Some of the tasks that are part of this management function include implementation and tracking of continuous quality improvement and quality control, as well as performance measures for department functions and outputs (Braveman, 2014). When applied to diversity issues, these tasks include maintaining and reviewing data from patient satisfaction scores, as well as ongoing health disparities data (HRET, 2013). Although there is increasing research on the positive impact of managing diversity in the workplace in fields outside of occupational therapy (Saxena, 2014), more evidence is needed in the occupational therapy profession as well. Therefore, this management function of valuing and maintaining diversity must not be overlooked. Gardenswartz and Rowe (2010) discussed how to design an evaluation strategy and how to measure various data, as well as include samples of typical metrics that would be useful for any occupational therapy manager. Regardless of approach to evaluation, it should focus on 2 categories: (1) process and (2) results (Gardenswartz & Rowe, 2010). Some questions might include ■ Process • Did we do what we set out to do? • How well did we do it? • What needs to be changed to do better? ■ Results • Did it make a difference? • What is the impact on organizational objectives? • What improvements can be seen resulting from this? • Did it achieve the results set out in the organization’s criteria? Establishing diversity initiatives is important but not sufficient. The way to sustain these efforts is to regularly evaluate the success and progress within the occupational therapy program and the larger organization. Review Questions 1. After reviewing the functions of an occupational therapy manager, what aspect of managing diversity will be the first you’ll address? Which seems most difficult for your department or organization? 2. Does your organization require diversity training? If not, how will you go about setting it up for your department? 3. Do you know other occupational therapy managers who are successfully managing diversity issues in their workplace? How might you use them to help guide your efforts? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 16. Promoting and Managing Diversity 165 CASE EXAMPLE 16.1. Sarah: Managing Diversity Sarah has worked as an occupational therapy practitioner for 9 years and is now a novice occupational therapy manager (4 months in the position) in a midsize hospital on the West Coast. She has become aware that 30% of the clients who come through her department are Asian, mostly from China, Japan, South Korea, and Laos. The occupational therapy department employs 6 occupational therapy practitioners—3 are White; 2 are African American, including herself; and 1 is a new graduate originally from Puerto Rico. Their ages range between 24 and 60 years. Sarah is in her early 30s. At first, Sarah felt that the department had diversity “handled” because of the ethnic diversity of the occupational therapy staff. However, she had noticed some tension between staff members, as well as between some occupational therapy staff and the clients. She knew these subtle issues needed to be addressed, but Sarah didn’t know how to begin. Sarah went to the rehab director to discuss these issues, and he told her that the organization had a diversity coordinator who might help. Jessica, a biracial woman in her early 40s, helped Sarah brainstorm how to manage these issues and stated that she was beginning a series of short training sessions soon. While talking to Jessica, Sarah realized she was becoming a little uncomfortable, and after agreeing to require the occupational therapy members in her department to attend these training sessions, she quickly returned to her own office. Review Questions 1. 2. 3. Do you think the hospital in the case is a culturally competent organization? What could Sarah do to assess this? What do you think caused Sarah’s discomfort? What might she do to reflect on this? Is requiring her staff to attend the trainings a good thing? What other approaches could Sarah do with the staff to address the tension she had noticed? SUMMARY Developing effective strategies to enhance the management of diversity within one’s department, program, and organization is complex and challenging, but it is absolutely necessary for effective care and services. This chapter introduced methods and strategies to address diversity management within typical functions of a manager. These tasks and strategies do not have to be accomplished quickly or at the same time but can be incorporated slowly by developing a strategic plan for change. After reviewing the research of a decade ago, Janice Dreachslin (2007), who has written extensively in the field of diversity, offered the following advice: Manage diversity. If left unmanaged, demographic diversity will interfere with team functioning. Identify a common ground among diverse groups, because similarity can pull different team members together. Invest in professional development so that team members have the tools they need to navigate their differences. (p. 83) ❖ ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ B.1.2. Sociocultural, Socioeconomic, Diversity Factors, and Lifestyle Choices ■ B.1.3. Social Determinants of Health ■ B.3.1. Occupational Therapy History, Philosophical Base, Theory, and Sociopolitical Climate ■ B.4.4. Standardized and Nonstandardized Screening and Assessment Tools ■ B.4.5. Application of Assessment Tools and Interpretation of Results ■ B.4.18. Grade and Adapt Processes or Environments ■ B.5.1. 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Retrieved from http://integralleadershipreview.com/7046 MaineHealth. (n.d.). Our values. Retrieved from https://maine -integral-leadership-and-diversity-definitions-distinctions-and health.org/about/our-values -implications Mor Barak, M. E. (2017). Managing diversity: Toward a globally inVon Bergen, C. W., Soper, B., & Foster, T. (2002). Unintended negclusive workplace (4th ed.). Thousand Oaks, CA: Sage. ative effects of diversity management. Public Personnel ManageNational Center for Health Statistics. (2010). Healthy People initiament, 31, 239–251. https://doi.org/10.1177/009102600203100209 tive. Retrieved from https://www.cdc.gov/nchs/healthy_people Weech-Maldonado, R., Dreachslin, J. L., Dansky, K. H., De Souza, /hp2010/hp2010_final_review.htm G., & Gatto, M. (2002). Racial/ethnic diversity management and National Center for Health Statistics. (2016). Health, United States, cultural competency: The case of Pennsylvania hospitals. Journal 2015: With special feature on race and ethnic health disparities. of Healthcare Management, 47, 111–126. Report 2016-1232. Hyattsville, MD: Author. Retrieved from Wells, S. A., Black, R. M., & Gupta, J. (2016). Model for cultural efhttps://www.cdc.gov/nchs/data/hus/hus15.pdf fectiveness. In S. A. Wells, R. M. Black, & J. Gupta (Eds.), Culture National Center for Health Statistics. (2017). Health, United States, and occupation: Effectiveness for occupational therapy practice, 2016: With chartbook on long-term trends in health. Retrieved education, and research (3rd ed., pp. 65–79). Bethesda, MD: from https://www.cdc.gov/nchs/data/hus/hus16.pdf AOTA Press. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Volunteering: Staff Participation Outreach and Contributing to the Community Mary J. Hager, MA, OTR/L, FAOTA CHAPTER 17 LEARNING OBJECTIVES After completing this chapter, readers should be able to: ■ ■ ■ ■ ■ ■ Describe real-life examples of volunteering, Recognize who can volunteer, Understand the value of becoming a volunteer, Identify the most common types of volunteers, Recognize local opportunities for volunteering, and Describe the opportunities for volunteering within the state and national occupational therapy organizations. KEY TERMS AND CONCEPTS • Networking • Occupational engagement • Pro bono • Service learning OVERVIEW A volunteer is a person who donates their time or efforts for a cause or organization without being paid (“Volunteer,” n.d.). Providing a service to others in the health profes­ sion is called pro bono, which is a Latin phrase for professional work done as a volunteer without payment. The reasons to vol­ unteer are as varied as the people who volunteer. Some people volunteer because they see a need in their community, some have an interest they want to promote (e.g., arts, sports, politics), and others may have extra time and want to use it productively. Occupational therapy, sometimes known as a helping pro­ fession, is made up of caring professionals who are valuable assets to countless volunteer endeavors, helping individuals, communities, and the profession at large. Occupational ther­ apy managers can encourage and influence those they su­ pervise to pursue volunteer activities. This chapter discusses what is meant by volunteering and gives real-life examples of the types of volunteer opportunities available. ESSENTIAL CONSIDERATIONS Anyone can volunteer. Although many people feel that they do not have the time, energy, or expertise to volunteer, giving even • Skill acquisition • Volunteer a little effort to an organization or collective project can make a valuable difference. Volunteers are everywhere—in hospitals, re­ habilitation centers, schools, churches, the military, businesses, and communities. Occupational therapy practitioners can use their knowledge and skills in unique and beneficial ways. As volunteers, they are often asked to work with people with many types of disabilities 1-on-1 and in groups to identify entertain­ ing activities that help in skills development and social interac­ tion, to coordinate projects with short- and long-term goals, to work with parents and caregivers, and to find funding sources. Benefits of Volunteering The many benefits of volunteering are generally recognized by those who volunteer. Volunteering can ■ ■ ■ ■ Connect one to others, Be good for one’s mind and body, Advance one’s career, and Bring fun and fulfillment to one’s life (Segal & Robinson, 2018). Regular volunteering positively affects subjective well-being, and that feeling of satisfaction increases over time if volunteer­ ing is sustained (Binder & Freytag, 2013). Occupational therapy Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.017 167 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Volunteering: Staff Participation Outreach and Contributing to the Community Mary J. Hager, MA, OTR/L, FAOTA CHAPTER 17 LEARNING OBJECTIVES After completing this chapter, readers should be able to: ■ ■ ■ ■ ■ ■ Describe real-life examples of volunteering, Recognize who can volunteer, Understand the value of becoming a volunteer, Identify the most common types of volunteers, Recognize local opportunities for volunteering, and Describe the opportunities for volunteering within the state and national occupational therapy organizations. KEY TERMS AND CONCEPTS • Networking • Occupational engagement • Pro bono • Service learning OVERVIEW A volunteer is a person who donates their time or efforts for a cause or organization without being paid (“Volunteer,” n.d.). Providing a service to others in the health profes­ sion is called pro bono, which is a Latin phrase for professional work done as a volunteer without payment. The reasons to vol­ unteer are as varied as the people who volunteer. Some people volunteer because they see a need in their community, some have an interest they want to promote (e.g., arts, sports, politics), and others may have extra time and want to use it productively. Occupational therapy, sometimes known as a helping pro­ fession, is made up of caring professionals who are valuable assets to countless volunteer endeavors, helping individuals, communities, and the profession at large. Occupational ther­ apy managers can encourage and influence those they su­ pervise to pursue volunteer activities. This chapter discusses what is meant by volunteering and gives real-life examples of the types of volunteer opportunities available. ESSENTIAL CONSIDERATIONS Anyone can volunteer. Although many people feel that they do not have the time, energy, or expertise to volunteer, giving even • Skill acquisition • Volunteer a little effort to an organization or collective project can make a valuable difference. Volunteers are everywhere—in hospitals, re­ habilitation centers, schools, churches, the military, businesses, and communities. Occupational therapy practitioners can use their knowledge and skills in unique and beneficial ways. As volunteers, they are often asked to work with people with many types of disabilities 1-on-1 and in groups to identify entertain­ ing activities that help in skills development and social interac­ tion, to coordinate projects with short- and long-term goals, to work with parents and caregivers, and to find funding sources. Benefits of Volunteering The many benefits of volunteering are generally recognized by those who volunteer. Volunteering can ■ ■ ■ ■ Connect one to others, Be good for one’s mind and body, Advance one’s career, and Bring fun and fulfillment to one’s life (Segal & Robinson, 2018). Regular volunteering positively affects subjective well-being, and that feeling of satisfaction increases over time if volunteer­ ing is sustained (Binder & Freytag, 2013). Occupational therapy Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.017 167 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 168 SECTION II. Organizational Planning and Culture CASE EXAMPLE 17.1. Braille Trail As a new occupational therapist in 1975, I moved to Cross Lanes, West Virginia, and did not know many people. Early in my career I joined the Junior Woman’s Club and, at their first meeting, heard about a project that had not gotten off the ground. The president talked about a braille trail that they had hoped to build in Kanawha State Forrest, but they couldn’t find members who wanted to get it going. As an occupational therapist, I knew I had something to contribute, so I raised my hand and offered to help. From that first moment, many exciting things began to happen, and my appreciation for volunteering began to peak. First came a meeting with the forestry director, who looked over plans from several years in the past and agreed to help our group with the project. I had the opportunity to talk to him about occupational therapy and how we could expand the idea to a trail that would be accessible to people who were visually and physically challenged and all individuals who wanted to participate in nature. This encounter led to writing grants and obtaining state funding. As a result, other organizations were willing to give their time and money to the project. I wrote letters to the West Virginia governors in different administrations to encourage them to support the project. In every letter I explained the scope of our profession and why occupational therapy was involved. After many months, the Spotted Salamander Accessible Trail had its grand opening. It was a thrill to take school teachers and students with disabilities to the trail and know that they could enjoy the forest (Surber, 1987). practitioners can set examples for their clients. For example, residents in long-term care facilities improved their well-being by volunteering (Yuen et. al., 2008). Service learning is an educational approach to volunteering that can benefit both the provider and the recipient by com­ bining learning objectives with community service (Horowitz, 2012). Service learning has long been used in occupational therapy education and can benefit students and communities. For example, occupational therapy students who volunteered to help children make better nutrition choices found service learning to be a valuable learning experience (Lau, 2016). Sim­ ilarly, occupational and physical therapy students participating internationally in Belize reported they felt better prepared for interprofessional practice than their peers (Beitman et al., 2016). Local Opportunities Case Examples 17.1–17.3 provide examples of local volunteer opportunities where the skills of an occupational therapist were effectively applied. Local organizations may include CASE EXAMPLE 17.2. volunteering for scouting programs, sports such as Little League or soccer, religious institutions, and many other organizations. Most newspapers publish notices of organizations seeking volunteers and have long lists in their community sections. Case Example 17.1 shows how an occupational therapy back­ ground can greatly enhance an important community project. Case Example 17.2 shows how an occupational therapist combined the love of a sport and therapy skills to create adap­ tations so any child could play and participate in an activity that is meaningful to them. Review Questions 1. List 3 activities that interest you (e.g., sports, art, music). What volunteer opportunities might be available related to these areas? 2. What is service learning? How does it benefit students and communities? 3. What occupational therapy skills would be useful when volunteering? Challenger Baseball Challenger Baseball (Little League Challenger Division) afforded another local opportunity to help the community and expand the knowledge of occupational therapy to people who otherwise may not have known anything about the field. In 1983, my husband, who was on the board of the Cross Lanes Little League, came home after a weekly meeting and asked if I knew of any children with disabilities who might like to play baseball. This started another venture in volunteerism. Because I was working as a school-based occupational therapist, I told him that I was sure I knew children who would like the opportunity to play baseball. The Cross Lanes Little League president had heard about Challenger Baseball and wanted to see about starting a team in Cross Lanes, West Virginia. I called several of the parents of the children I was treating, and many of them gladly said yes. From that first season, I worked with the team for 23 years using adaptations and assistive devices to enable the children to be competitive in play. It is almost impossible to explain how happy the children were while playing baseball. They performed to the best of their ability and were so proud to play in their new uniforms. I came up with adaptations such as using an extremely soft ball and hollow plastic bat for safety so no one would get injured. Another adaptation was using flat bases so wheel chairs could easily pass over them and did not pose a tripping hazard. An unexpected outcome came from encouraging the regular baseball teams to take turns helping our players. They soon became friends and buddies to our players and even helped them with school projects. The Challenger teams were also invited to play a game on the local minor league baseball team field at the end of a regularly scheduled game. Each player was announced on the PA system when he or she came to bat, and their picture appeared on the large screen in the stadium. The professional players from the minor league team assisted the players with special needs during the game (Hager, 2010). One Boy Scout and two Girl Scouts earned their Eagle Award and Gold Awards, respectively, by doing their merit projects on our Challenger Field to make it more accessible and fan friendly. These projects resulted in newspaper articles being written, and each time occupational therapy was mentioned, which is good recognition for the profession. I was honored to receive a Jefferson Award for this work. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 17. Volunteering: Staff Participation Outreach and Contributing to the Community CASE EXAMPLE 17.3. 169 Working With Veterans and Young Adults With Disabilities I volunteered at a local community center that provides training in basic living skills for 18 young adults with physical or mental disabilities. These young men and women had limited options or opportunities for training and social interaction from other resources. Volunteers and a paid director run the facility. One of my activities was to set up and coordinate a project concerning veterans. For several months, the students interviewed veterans based on questions they had chosen during a class planning session. The veterans included family, friends, and neighbors. After the interviews, the students wrote or typed their work, which was compiled in a finished product. One of the students used the video feature on his smartphone to record his mother’s thoughts about her husband receiving a Quilt of Valor, which is sponsored by the Quilts of Valor Foundation to cover service members and veterans touched by war. The quilts provide comfort and are symbolic of healing. The interview project concluded with a parent day where the students read, to the best of their ability, their interviews with the veterans to the audience. Two of the students used their iPads with a special voice feature to assist them with their presentation. Several students served food they had prepared and sang patriotic songs. The event was an enormous success and, according to the school director, received many favorable comments. I presented this information at an occupational therapy symposium attended by occupational therapy students, faculty, and clinicians to provide an example of how occupational therapy skills can be used in volunteer activities (Hager, 2018). PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Occupational Engagement As Stoffel (2015) described, As occupational therapy practitioners, we use occupational engagement as a key strategy to connect with the people we serve. We get to know what matters to them and what they view as their meaningful, necessary, and familiar activities of everyday life that will facilitate participation so as to improve health and quality of life. (p. 1, bold and italics added) Like their clients, occupational therapy practitioners are oc­ cupational beings who engage in meaningful occupations CASE EXAMPLE 17.4. by choice. Reflecting on one’s own valued occupations is a good place to start when searching for a meaningful volunteer role. When volunteering, occupational therapy practitioners are uniquely skilled at identifying what others value and using it to engage them and improve their occupational well-being. Case Example 17.4 shows how young adults’ love of the outdoors created a way to improve performance skills and occupationally engage. Expanding Volunteer Opportunities Volunteering often creates opportunities for others, includ­ ing occupational therapy coworkers, to become involved in an activity or project. This also increases the amount of Love of Nature When I first started volunteering at the local community center for adults with disabilities, I had no idea how I could help them. All I knew was that they were looking for volunteers to work with young adults 2 mornings a week. It took a little time to get to know the students, but gradually I did. The students were diagnosed with conditions that included autism, Down syndrome, cerebral palsy, and learning disabilities. One of the things that struck me was their love of nature. After talking with the director, I came across the idea for “I love nature because . . .” I wanted a topic that would interest them and one where they would be required to make decisions. This idea seemed like a perfect way to combine their interests and mine. The topics ranged from giraffes to warm springs. The students’ intellectual and mechanical writing abilities varied greatly. Some could print legibly, and others used a computer to communicate. The project involved using smartphones, computers, and assistive devices to help the students with special needs participate. Smartphones were chosen because they have cameras, they provide Internet access, they are easy to understand, and they are frequently used in real-life situations. Taking pictures and writing stories was fun for the students. Assistive devices such as large letter keyboards and special remote keypads were used with a standard or laptop computer to help them perform the necessary tasks. Over several months, the students took pictures of various things in nature using smartphones. Additionally, they typed narratives into Microsoft Word to complete the phrase “I like nature because.” All of the students, regardless of ability, were able to participate and enjoyed seeing their work appear on the screen. For some students, computer-assistive devices facilitated data entry. They learned how to type or improve their typing skills, how to transfer pictures from smartphones to a computer, and how to print their narratives and pictures for use in a publication. At the end of the summer, all of the students participated in a special parent night at a local library where they read their narratives or used an iPad with Proloquo2Go to communicate with the audience. As an occupational therapist, I served an essential role in helping the teacher decide which devices and activities were appropriate. Review Questions 1. What skills do you have that could be useful as a volunteer? 2. List 3 occupations that you value. 3. What technical skills could you bring to a volunteer activity? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 170 SECTION II. Organizational Planning and Culture CASE EXAMPLE 17.5. National Volunteer Opportunity I started the Devereaux Project in the summer of 2014 with the encouragement of members of the American Occupational Therapy Foundation (AOTF). The Devereaux Archival Project is intended to gather and archive the most important historical information from the state associations. The information will be stored electronically in the AOTF Wilma West Library, where it can be easily accessed. The project is named in honor of Elizabeth Devereaux, who passed away in 2010. Liz was a past president of the AOTF and held many offices in the West Virginia Occupational Therapy Association. She was always supportive of saving the history of occupational therapy, especially of the state associations. Several requests were sent via the Representative Assembly (RA) and State Association Listserv with assistance from the speaker of the RA and chair of the Affiliated State Association Presidents (Pugh, 2015). A table was designed to request historical information about the association, its presidents, its representatives, and the people most important to the advancement of occupational therapy in the state along with a brief description of their contributions. As of this writing, volunteers from 27 states have sent in information with many more states indicating that they plan to do so. The project has exceeded my expectations because several state volunteers have sent not only the basic information but additional historical documents as well. energy that can be applied to a project and enables others to apply their unique skills and knowledge to a specific endeavor. These new volunteers might eventually take over project leadership responsibilities. Once a person volunteers, they are more likely to pursue other volunteer activities in the future (Segal & Robinson, 2018). Case Example 17.5 de­ scribes a project that was started and led by one person but gave many other individuals an opportunity to volunteer and contribute. Using Volunteering to Expand Knowledge and Skills Volunteering can expand one’s own skills and talents. Some projects require learning new skills that one otherwise would not need to learn or apply (see Case Example 17.6). Vol­ unteering can help occupational therapy practitioners and managers gain skills in financial management, negotiation, marketing, social media, technology, and so forth (Carpenter, 2018). Practitioners who take on volunteer responsibilities often develop leadership skills because they frequently have to coordinate activities and work with many people to achieve the project objectives. Using Volunteering to Network Volunteering is a form of networking in that it allows vol­ unteers to meet and get to know people who they may not CASE EXAMPLE 17.6. otherwise interact with. Some of these people might provide new experiences, mentoring, and knowledge. Some organi­ zations have experienced and influential individuals on their boards of directors, and these people support the same cause for which one is working. Advocacy is an important type of networking. Being po­ litically active and advocating for occupational therapy of­ fers wide-ranging volunteer opportunities for occupational therapy practitioners and students. It is also a fantastic way to network with individuals and groups on a local, state, or national level. The American Occupational Therapy Associ­ ation’s (AOTA’s) Hill Day brings hundreds of occupational therapy practitioners, students, and educators together in Washington, DC. Advocates meet with their representa­ tives on Capitol Hill to explain what occupational therapy is and how it benefits their constituents and communities. AOTA’s 2018 Hill Day involved more than 500 advocates from 39 states who advocated and networked together. Case Example 17.7 describes networking and advocacy at the state level. Cultivating Volunteerism in the Workplace Occupational therapy managers can cultivate a culture of volunteerism and inspire staff to volunteer in several ways. Some organizations sponsor volunteerism by “paid-­release” programs that allow volunteering on company time. Millennial workers, who, more than other generations, tend Learning New Skills I am not especially tech savvy but wanted to learn and do as much as possible with technology. Learning a new skill is an effective way of experiencing firsthand how difficult skill acquisition, which refers to how new behaviors and skills are learned, can be for people with disabilities. In the example of Case Example 17.4, I needed to learn how to transfer pictures from a smartphone to a computer and then print them so I could teach the students. This skill may be easy for some people, but it was difficult for me. First, I had to find someone who was willing to teach me and then patient enough to let me practice. After a few attempts, I became proficient and felt confident in transferring my learning to the students. Now I often use this new skill in family projects. Without volunteering, I probably never would have mastered this. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 17. Volunteering: Staff Participation Outreach and Contributing to the Community CASE EXAMPLE 17.7. 171 Day at the Legislature The West Virginia Occupational Therapy Association (WVOTA) conducts a Day at the Legislature every year. We ask for volunteers from the occupational therapy community to help. This brings together occupational therapy practitioners, students, and faculty from around the state. Participants volunteer part of the day or the entire day as they are able. We ask the students to contact their legislators and make appointments. Often a seasoned occupational therapy practitioner will accompany a student to an appointment. In addition to the appointments, exhibits are set up, and exhibitors speak with legislators and the general public about occupational therapy and its importance to the community. Relevant legislation may also be discussed. For example, the 2017 WVOTA Legislative Day offered an opportunity for WVOTA members to share their concerns about opioid abuse with their legislators and suggest how occupational therapy could help. Additionally, members of WVOTA’s legislative committee met with the attorney general and his staff to make them aware of a motion dealing with opioid abuse in the AOTA RA. This contributed to occupational therapy services being included in an opioid alternatives bill that became law in West Virginia (Hager, 2017). to seek employment that aligns with their values, partic­ ularly appreciate opportunities to volunteer while at work (Zimmerman, 2016). Such programs can increase employee morale and commitment to the organization. In addition, the vast majority of American workers believe that compa­ nies that sponsor volunteer activities have a better overall working environment than those organizations that do not (Deloitte, 2017). Occupational therapy managers can help employees un­ derstand how their volunteering benefits the community. Supporting and engaging with the causes employees value can also foster a volunteer culture. Managers can provide time to work on volunteer projects and activities and recognize the volunteer’s efforts verbally or with a plaque or certificate. Additionally, they can show their support by participating in some of the volunteer activities. This helps build camaraderie that can carry over to the workplace. the workplace. Occupational therapy managers can play a key role in supporting and encouraging volunteerism. ❖ Review Questions REFERENCES 1. What leadership skills could be derived from volunteering? 2. How does volunteering help with networking? 3. List 3 examples of what a manager could do to encourage volunteering. Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org /10.5014/ajot.2018.72S217 Beitman, C., McAfee, E., Hensley, A., Giesler, L., Linville, M., Mosier, M., & Gardner, E. (2016). Service learning in Belize: Percep­ tions of occupational and physical therapy students and alumni [poster session]. American Journal of Occupational Therapy, 70, 7011510209p1. https://doi.org/10.5014/ajot.2016.70S1-PO4045 Binder, M., & Freytag, A. (2013). Volunteering, subjective well-­being and public policy. Journal of Economic Psychology, 34, 97–119. https://doi.org/10.1016/j.joep.2012.11.008 Carpenter, A. (2018, January 30). 5 ways volunteering can enhance your career. Forbes. Retrieved from https://www.forbes.com/sites /alissacarpenter/2018/01/30/5-ways-volunteering-can-enhance -your-career/#5620d01b7962 Deloitte. (2017). 2017 Deloitte volunteerism survey. Retrieved from https://www2.deloitte.com/content/dam/Deloitte/us/Documents /about-deloitte/us-2017-deloitte-volunteerism-survey.pdf Hager, M. (2010, February 10). Challenger baseball: Living life to its fullest: OT reflections from the heart, OT Practice, 8(2), 33. Hager, M. (2017, July 24). West Virginia efforts against opioid abuse. OT Practice, 22(13), 3. SUMMARY This chapter used real-life case examples to illustrate how volunteering can benefit occupational therapy practitioners as well as those who are being helped. Indeed, occupational therapy practitioners are well suited to various volunteer activities, both from their education and training and their interest in helping people in need. Examples were presented that showed the diversity of volunteer opportunities, which range from local service activities to volunteering with state and national organizations such as the AOTA. Volunteers should be occupationally engaged in the activ­ ity and with the people they serve. In addition to the broadly recognized benefits of volunteering, occupational therapy students can benefit from service learning activities, and es­ tablished practitioners can advance their careers by expand­ ing their knowledge and making important contacts outside RESOURCES ■ Little League Challenger Division (https://www.littleleague .org/play-little-league/challenger/) ■ Volunteering and Its Surprising Benefits (https://www .helpguide.org/articles/healthy-living/volunteering-and -its-surprising-benefits.htm) ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ Preamble ■ B.7.3. Promote Occupational Therapy. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 172 SECTION II. Organizational Planning and Culture Hager, M. (2018, September 14). A volunteer project involving veterans and young adults with special needs. Poster presented at 75th Anniversary Symposium, University of Wisconsin–­ Madison. Horowitz, B. P. (2012). Service learning and occupational therapy education: Preparing students for community practice. Education Special Interest Section Quarterly, 22(2), 1–4. Lau, C. (2016). Impact of a child-based health promotion service-­ learning project on the growth of occupational therapy students. American Journal of Occupational Therapy, 70(5), 1–10. https:// doi.org/doi:10.5014/ajot.2016.021527 Pugh, E. (2015, April). Representative Assembly meeting minutes: Devereaux Project. https://www.aota.org/aboutaota/get-involved /ra/minutes.aspx Segal, J., & L. Robinson (2018). Volunteering and its surprising benefits. Retrieved from https://www.helpguide.org/ Stoffel, V. (2015). Engagement, exploration, empowerment. American Journal of Occupational Therapy, 69, 69061400. https://doi.org /10.5014/ajot.2015.696002 Surber, D. (1987, May 1). Project clears way for handicapped to hit the trail. Charleston Daily Mail, p. 1C. Volunteer. (n.d.). In YourDictionary.com. Retrieved from https:// www.yourdictionary.com/Volunteer Yuen, H. K., Huang, P, Burik, J. K., & Smith, T. G. (2008). Impact of participation in volunteer activities for residents living in longterm-care facilities. American Journal of Occupational Therapy, 62, 71–76. https://doi.org/10.5014/ajot.62.1.71 Zimmerman, K. (2016). Why company-sponsored volunteer programs are keeping millennials happy at work. Forbes. Retrieved from https://www.forbes.com/sites/kaytiezimmerman/2016/09/22 /company-sponsored-volunteer-programs-are-keeping-millennials -happy/#644188e578da Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] SECTION III. Navigating Change and Uncertainty Edited by Roger I. Ideishi, JD, OT/L, FAOTA, and Albert E. Copolillo, PhD, OTR/L, FAOTA 173 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Managing Organizational Change 18 Patricia Laverdure, OTD, OTR/L, BCP LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Identify the ways in which stakeholders and organizations understand, experience, and value change; ■ Recognize common characteristics of organizations that effectively implement change; ■ Describe the change implementation process and ways in which innovation can improve the efficiency, effectiveness, and value of occupational therapy services; and ■ Discuss strategies to evaluate change outcomes in health care enterprises, organizations, and staff. KEY TERMS AND CONCEPTS • • • • Change management Change outcome evaluation Competency drivers Implementation drivers • • • • Implementation science Leadership drivers Organizational change Organizational drivers OVERVIEW T o be successful in today’s health care market, managers must ensure that client services are effective, efficient, and affordable. Driven by regulatory, policy, and payment reforms that value high-quality, patient-centered care and reproducible cost-efficient results, managers are challenged to lead change and innovation in health care that minimize variations in health care and service delivery, inefficient processes and procedures, and waste that leads to inconsistent, unreliable, and costly outcomes. In this chapter, organizational change and change management strategies are examined in the context of health care administration and service delivery. Tools that enable managers to create vision and cultural urgency, identify change drivers and build organizational engagement, and effectively measure change outcomes (i.e., change outcome evaluation) are explored. By leveraging the power of an engaged workforce, occupational therapy managers can identify and overcome organizational barriers, establish transformative communication approaches, and design processes and programs that effectively usher in change in complex health care settings. • Readiness for change • Transformative communication Change and innovation, even in the context of stable and collaborative work environments, require team members to adopt new practices that may produce uncertainly and anxiety, disrupt processes that increase error in workflows, and affect client outcomes (Gosselin et al., 2015). Leading change in the midst of increasing health care complexity and fragmentation, shifting organizational structure and governance, and changing workforce demographics and pressures takes time and requires agility (Allan et al., 2014). A well-designed change implementation plan balances the organizational press for innovation with the professional identities of diverse team members and the emotions and relationships that exist within the organization (Allan et al., 2014; Andre & Sjovold, 2017). ESSENTIAL CONSIDERATIONS Organizational change is a transformational, intentional, and structured process of planning and implementing change in an organization’s structures, processes, and culture that maximizes the efficiency and effectiveness of the change effort. Change is difficult, yet it is necessary to maintain a relevant and effective service delivery system. Implementing change Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.018 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 175 176 SECTION III. Navigating Change and Uncertainty in complex systems requires far more than regulatory, procedural, and reporting structures. Organizational change influences the professional identities, satisfaction, and effectiveness of managers and staff alike (Allan et al., 2014). To effectively improve health care access and equity, service delivery processes, evidence-based innovation, and client outcomes, occupational therapy managers need to attend to all stakeholders and create agency and opportunity for the development of competency and leadership in change implementation. Foundations of Organizational Change and Change Management Key theories, models, and frameworks of organizational change Implementing and sustaining change in enterprises, organizations, and staff members requires careful planning and is often unsuccessful (Grimshaw et al., 2012). The complexity of an occupation-focused, client-centered, and evidence-based practice requires integration at the enterprise level (e.g., health care and social policy, organizational structure and function, information management), the organization or service provision level (e.g., care coordination and collaboration, service delivery systems, communication), and the staff member or service delivery level (e.g., client-centered evaluation, collaborative goal setting and problem solving, occupation-based intervention; Ehrlich et al., 2009; Valentijn et al., 2013). The field of implementation science offers clarifying concepts, definitions, and relationships that may help illuminate change mechanisms that bring about successful change at all levels in the health care system (Davidoff et al., 2015). Several key theories, frameworks, and models (labeled as models in this chapter) have been shown to have utility in health care change implementation (Table 18.1). Moullin et al. (2015) conducted a systematic review of implementation models in health care; although these change models may vary in the type of innovation (e.g., setting, population, preventive/ restorative, targeted or holistic) and the sequence and stages that change moves through, they provide important guidance for change design and implementation. Moullin et al. identified numerous models that inform change design, implementation, and sustainability, and although no one model addresses change requirements of all practice settings, Moullin et al. suggested that occupational therapy managers should consider the following during the planning of change implementation: ■ The innovation to be implemented and the evidence that ■ ■ ■ ■ supports it, The context in which the implementation is to occur, The influencing facilitators and barriers to change, The process (stages and steps) of implementation, and The evaluations that will be used to measure change success. Agents of change Achieving successful change in health care requires the presence of effective change leaders at varying levels throughout the enterprise, a strong relationship between managers and staff, and a cogent and coherent change strategy (Allan et al., 2014; Fitzgerald et al., 2007). Distributed leadership involving senior administrators who support the change and innovation, “credible opinion leaders” (Fitzgerald et al., 2007, p. 70) who network successfully with all stakeholders and establish clear priorities and support, and willing staff who engage actively in the change effort are essential for effective change and innovation implementation. Allan et al. (2014) suggested that during change efforts, staff are often “uncertain about their new roles and responsibilities, feel overworked, and are concerned that their effectiveness has been compromised” (p. 103). Effective interprofessional relationships between change leaders and those who implement change are critical for success (Fitzgerald et al., 2007). Fixsen et al. (2005) defined the agents of change as “implementation drivers” (p. 28), the human and material engine of change implementation within an enterprise. Implementation drivers are dynamic and interact with one another to facilitate innovation and empower change efforts. Fixsen et al. identified the active and integrated drivers of change as ■ Competency drivers: A selection of key competencies ■ ■ for innovation and the resources, training, and coaching required for effective performance; Organizational drivers: Organization support systems, policies and practices, and data systems that facilitate decision making and performance; and Leadership drivers: The adaptive (group cohesion and collaboration) and the technical (goals and effort) resources of the enterprise. Readiness for change Readiness for change is an organization’s level of understanding of the need for change, belief in the capacity to change, and commitment to the change process. Despite a dearth of evidence on organizations’ readiness for change (Spaulding et al., 2017), workforce culture is considered crucial to the success of change implementation (Jacobs et al., 2015). “An organization’s culture is reflected by what is valued, the dominant managerial and leadership styles, the language and symbols, the procedures and routines, and the definitions of success that make an organization unique” (Cameron & Quinn, 2006, p. 17). In their study examining the characteristics of a work culture that influences change, Andre and Sjovold (2017) compared the behaviors and interactions between health care personnel in 2 different units at the same hospital—one that had successfully implemented and sustained change and innovation, and one that struggled with internal and external barriers to change leading to unsuccessful change efforts. The authors found that the unit that successfully negotiated change achieved a balance of acceptance, engagement, independence, and loyalty. Members of the successful unit were focused on task completion and achievement of common goals. Andre and Sjovold (2017) reported a higher level of empathy and maturity both in independent and collaborative work Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] TABLE 18.1. Key Theories, Frameworks, and Models That May Have Utility in Implementing Change in Occupational Therapy Organizations, Programs, and Staff THEORY, FRAMEWORK, OR MODEL KEY COMPONENTS OCCUPATIONAL THERAPY PROCESS, INNOVATION, AND CONTEXT Capacity for Sustainability Framework (Schell et al., 2013) Implement and sustain innovative prevention programs to address issues in the public health domain Developing and establishing sustainability mechanisms for population-based occupational therapy interventions that are geared toward health risk prevention in community-based public health programs at the departmental, enterprise, and community levels Conceptual Framework of Complex Innovation Implementation (Helfrich et al., 2007) Design and implement effective and efficient processes and organizational protocol Designing and implementing processes for utility and efficiency in complex health care organizations at the departmental and enterprise levels Core Implementation Components (Fixsen et al., 2009) Design and implement evidenced-based prevention and treatment services and programs; emphasis on implementation stages and knowledge translation efforts Designing, implementing, and evaluating treatment protocols and evidence-based prevention strategies and interventions in human services settings at the individual, departmental, enterprise, and community levels General Theory of Implementation (May, 2013) Build awareness of, design, and predict impacts of innovative and complex interventions Building awareness and staff buy-in, designing dynamic implementation processes, and predicting impacts of processes in diverse clinical settings at the individual, departmental, and enterprise levels Normalisation Process Theory (May & Finch, 2009) Design, embed, and implement effective and efficient processes and organizational protocol in complex practices; prediction of impacts of change in processes; shared decision making Designing, embedding, and implementing processes for utility and efficiency in complex private practice organizations at the individual, departmental, and enterprise levels Practical Robust Implementation and Sustainability Model (PRISM; Feldstein & Glasgow, 2008) Design, implement, and evaluate outcome measurement of evidence-based interventions and technologies in health care settings Designing, implementing, evaluating, and sustaining treatment protocols and evidence-based interventions and technologies in health care settings at the individual, departmental, and enterprise levels Identifying factors that influence change uptake to support successful practice change implementation in health care settings at the individual level 10-Step Model for Inducing Change in Professional Behavior (Grol & Wensing, 2004) Identify determinants of change implementation Identifying factors that influence change uptake, developing barriers and incentives to change behaviors, and tailoring intervention to achieve desired professional behaviors in health care settings at the individual, departmental, and enterprise levels Advancing Research and Clinical Practice Through Close Collaboration Model (Melnyk et al., 2010) Define implementation steps and sustainability in the use of evidence to improve client outcomes Designing, implementing, evaluating, and sustaining use of evidence in evaluation and intervention to improve client outcomes in health care systems at the departmental and enterprise levels Dynamic Knowledge Transfer Capacity Model of Change Implementation (Parent et al., 2007) Analyze complex systems and knowledge needed for effective decision making; steps to support the transfer of knowledge within systems Establishing knowledge access, uptake, integration, and transfer mechanisms to enhance data-based decision making in complex health and human services systems at the departmental, enterprise, and community levels Promoting Action on Research Implementation in Health Services (PARiHS; Kitson et al., 2008) Implement evidence-based practices in evaluation and intervention Designing methods to increase use of evidence in evaluation and intervention in hospital settings at the individual, departmental, and enterprise levels Sticky Knowledge (Elwyn et al., 2007) Identify determinants of change in the use of evidence Identifying and mitigating barriers to implementation of evidence-based practice in primary and community-based services at the individual, departmental, and enterprise levels Note. Additional research is necessary to determine applicability and utility of these models for use in diverse and emerging occupational therapy practice areas. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 177 Model Matrix of Factors in Implementation Identify determinants of change in the implementation of of Practice Change (Hader et al., 2007) practice guidelines CHAPTER 18. Managing Organizational Change Knowledge Advancement Intervention Implementation TYPE 178 SECTION III. Navigating Change and Uncertainty in the successful unit. The unit that was less successful in negotiating change was characterized by a culture of complaints, dissatisfaction, and passivity. Personnel on the unsuccessful unit reported feelings of self-sacrifice and lack of joy in their work. Volker et al. (2017) suggested that to effect change in environments in which resistance is high, occupational therapy managers must improve the “value proposition” (p. 8) of the change effort. Occupational therapy managers need to leverage leadership within the enterprise and organization and among their staff to strengthen commitment to common goals, complete shared tasks, and facilitate change (Berg, 2001; Sijpkens et al., 2016). To engage staff and facilitate absorption of change and innovation, leadership must strike a balance between providing essential guidance through clear processes, structures, and rules, and empowering staff’s creativity and adaptive capacity (Brown & Eisenhardt, 1997). Engaging staff members in structured and collaborative decision making fosters understanding, acceptance, and loyalty, laying the groundwork for managers to usher in necessary change (Craig et al., 2017). Spaulding et al. (2017) examined organizational readiness for change and developed a measurement scale that can accurately and reliably be used by occupational therapy managers to evaluate when and how to implement change in their organization. The Organizational Capacity for Change Measurement Tool identifies strengths across 3 dimensions: (1) transformative leadership, (2) relational culture, and (3) organizational technologies (administrative, clinical, information, social/communication; Spaulding et al., 2017). The survey of 25 questions is scored on a 5-point Likert rating scale, and by comparing the results across the dimensions, occupational therapy managers can develop processes, tools, and resources and target key strategies that effectively prepare staff for innovative change initiatives. Change Implementation Process Adapting to practice trends and improving the quality of services require change. Although change challenges enterprises, organizations, and staff, when carefully planned and implemented, change can be a professional growth opportunity for all stakeholders involved (Oake et al., 2017). The change and innovation process begins with identification of the urgency for change and the development of a communication plan that enables all stakeholders to collaborate on a blueprint for change implementation and sustainability (Oake et al., 2017). Kotter’s (2001) 8 steps of change offers occupational therapy managers a clear process by which to establish the blueprint of change and step through the process of creating a climate for implementing and sustaining change. In Kotter’s model (Figure 18.1), occupational therapy managers create a readiness for change, leverage leadership to build buy-in, and activate all staff to establish a vision and implementation plan for change. Kotter’s 8 steps include 1. 2. 3. 4. 5. 6. 7. 8. Establish a sense of urgency. Create a guiding team. Develop a change vision. Communicate a vision for buy-in. Empower action. Generate short-term wins. Don’t let up. Make it stick. FIGURE 18.1. Kotter’s 8 steps of change. Implement and sustain change 7 Engage and enable 5 Create a climate for change 4 3 2 1 8 6 Make it stick Don’t let up Generate short-term wins Empower action Communicate a vision for buy-in Develop a change vision Create a guiding team Establish a sense of urgency Note. Steps from Kotter (2001). Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 18. Managing Organizational Change Create a climate for change During Kotter’s first 4 steps of change, the occupational therapy manager identifies the need, builds consensus among diverse stakeholders, and creates a climate for change. The occupational therapy manager assesses the needs of stakeholders, accesses and links research and practice, and builds awareness of the need for change (Parent et al., 2007). In Step 1, collaborative discussions are key to persuade staff and establish a sense of urgency. Step 2 calls for the manager to create a guiding team made up of credible and influential organizational leaders who are empowered to work together with creativity and imagination to develop a change vision, Kotter’s Step 3. In Step 4, the occupational therapy manager and the guiding team communicate a vision for buy-in, and the manager allocates the necessary resources for successful change implementation (Packard, 2017). The vision should be simply and clearly communicated; organizational leaders cannot overcommunicate the urgency for change (Kotter, 2001). The guiding team’s experiences and early adoption of the vision for change are instrumental in mitigating resistance and building hope in the change process. Engage and enable the organization Kotter’s next 2 steps build on the needs assessment and collaborative visioning to foster organizational commitment and competency. Staff plan and develop iterative mechanisms to empower action (Step 5) and achieve initial short-term wins (Step 6). During this phase of planning and implementation, the occupational manager builds the commitment of stakeholders and prepares them for success in implementing the change (Parent et al., 2007). Resources are created, and training and coaching are provided. Implement and sustain action In the final 2 steps, the occupational therapy manager, the guiding team, and the committed stakeholders implement the change plan. Shatpattananunt et al. (2015), in their CLEVER (Context and Culture, Leader, Effective Driving Change, Voice, Empowerment, and Reaudit) Model, describe the processes of this phase as “unfreezing (increasing driving forces and reducing resistance force to change), moving (taking action for change), and refreezing (stabilizing the change at a new equilibrium)” (p. 363). The occupational therapy manager carefully monitors the stages of change, utilization and absorption of new knowledge, acceptance of change, and outcomes of the change process. During this final stage, momentum is built, leadership is distributed, and communication and plan mechanisms are upgraded as needed (Parent et al., 2007). The occupational therapy manager and guiding team members continue to reinforce the change effort until it is adopted and fully implemented. Once change is fully implemented, outcomes are visible and the change effort is reinforced and 179 often celebrated by all stakeholders. Through effective change implementation, the culture of the organization sustains the change effort. Methods of evaluation Change outcome evaluation is the process by which the outcomes of the change implementation effort are measured. Measuring the outcomes of change is an essential component of the change process, and outcomes communicate value to program stakeholders. Identifying explicit targets and measures during the planning stages and using them during the implementation stages allow occupational therapy managers to effectively manage change effort resources and make necessary trajectory changes in change implementation. Occupational therapy managers use both activity and outcome measures to evaluate the effectiveness during and at the end of the change effort (Newton, 2011). Activity measures enable managers to evaluate the progress of the change effort, whereas outcome measures evaluate what was achieved by the effort. When developing activity and outcome measurement methods, managers need to consider the recipients of the change effort and the intended impact of the change effort on the recipients. The purpose of the data to be collected must be considered in the planning stages. For example, the collection methods of specific metrics required by upper management, funding sources, consumers, or providers can be established when developing activity measures or outcome measures. To effectively develop activity and outcome measures, Linnell (2003) suggested the following: ■ Begin with the end in mind: Consider the vision for the ■ ■ ■ ■ change effort and design methods of evaluation before the implementation stage. Involve stakeholders: Build buy-in and determine the metrics that will be important to maintain stakeholder commitment. Align closely with needs assessment: Maintaining align­ment with the needs assessment data allows the occupational therapy manager to show improvement from baseline and facilitates measure of capacity-building efforts. Understand the context: Customize the measures according to the specific needs of the enterprise, organization, and staff. Use the evaluation for learning: “The ultimate purpose of evaluation should be focused on continuous learning and developing practices that move organizations toward greater effectiveness” (Linnell, 2003, p. 9). Organizations that use activity and outcomes measures for continual learning show great success in organizational change and innovation (Linnell, 2003). Change management is the art and science of designing and supporting individuals and organizations to adopt change efforts that improve processes and outcomes. Change management activity measures may include tracking milestone completion and adherence to timelines; communication plan effectiveness; training preparation, attendance, and Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 180 SECTION III. Navigating Change and Uncertainty effectiveness measures; and employee engagement and participation measures. Change management outcome measures may include stakeholder feedback; behavioral change; efficiency, proficiency, and performance measures; compliance measures; and client outcomes. Review Questions 1. What are common components of implementation change theories, models, and frameworks that support successful organizational change implementation and sustainability? 2. Compare and contrast the roles of the key change implementation drivers. 3. Describe the steps involved in change implementation, sustainability, and outcome measurement in health care. PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY In today’s health care environment, occupational therapy managers must be equipped to effect change that increases access and equity, improves service delivery processes, embraces evidence-based innovation, improves client outcomes, and increases the value of services. Through effective change leadership and implementation, occupational therapy managers ensure that services delivered increase the meaningful occupational opportunities for the organization’s clients and improve the value of the service and the profession. Drawing on an understanding of models of change implementation, change agents, and processes of change implementation, occupational therapy managers leverage change leaders, the change effort life cycle, and tactical change leadership to adopt change in the workplace (Gocsik & Barton, 2014). The change effort life cycle is a systematic process that enables occupational therapy managers to create a changeready organization and implement evidence-based innovation in health care and includes ■ ■ ■ ■ ■ Define and plan, Design, Build and test, Plan and deploy, and Operate and innovate. Define and Plan Aligning with Kotter’s (2001) Steps 1 and 2, the occupational therapy and service delivery processes and client and staff needs are evaluated to determine need for change. In occupational therapy, change may encompass the following (Heller & Arozullah, 2001): ■ Strategic issues: Program policy that affects client access ■ and service equity, limited personnel resources, or ineffective or inefficient workflow processes and procedures. Cultural disputes: Beliefs, values, norms, and behavior of the enterprise, organization, or staff that affect collaboration, teamwork, and opportunities to learn from mistakes. ■ Inadequate clinical or technical skills and procedures: Lack ■ of knowledge, preparation, training, and follow through on best practices. Structural limitations: Limited or inconsistent mechanisms to communicate and disseminate best practices. Occupational therapy managers identify the key stakeholders and workplace cultural characteristics and select the change effort to be addressed. Often, occupational therapy managers are faced with numerous needs and must prioritize based on an analysis of the organization, its readiness for change, and the review of the evidence and the change efforts’ likely impact on improvement in relevant outcomes (Heller & Arozullah 2001). Data are collected, carefully analyzed, and used to make decisions regarding needed change. Barriers to change, including personnel resistance and organizational change readiness, are identified and measured, and infrastructure and remediation strategies are implemented. Change leadership is empowered to develop a vision for change, and communication structures are established. Design During the design stage, the occupational therapy manager works with the change leadership and, in alignment with Kotter’s Steps 3 and 4, designs the processes that will be used in the innovation. Occupational therapy managers identify which components of the change effort are compliance driven and which are commitment driven and determine a change approach (Ireland, 2016). Build and Test Ensuring stakeholder commitment and aligning change processes with a strategic vision and plans of the enterprise, occupational therapy managers consider the ways that the design will affect clients, staff, and the organization before, during, and after the change effort. Targets and outcome measures are identified. Train and Deploy Consistent with Kotter’s Steps 5 and 6, occupational therapy managers train personnel and execute the change effort. Creating time and space to build capacity for change and innovation requires access to relevant resources, formal training (face to face or virtual), mentoring and coaching, and supervision. Communication is key, and occupational therapy managers must “Communicate the right message to the right people using the right vehicles” (Ireland, 2016, p. 279). Operate and Innovate Opportunity to observe and emulate practice exemplars is a valuable tactic in change implementation in occupational therapy. Aligning with Kotter’s Steps 7 and 8, occupational therapy managers create opportunities for ongoing support and distributed leadership among occupational therapy staff. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 18. Managing Organizational Change Reinforcement mechanisms (e.g., reward, negative consequences) with performance expectations are used. Additional operational and quality metrics and outcome data are collected by soliciting feedback from stakeholders, and data are analyzed for additional training and advanced processes. Communication In implementation science literature, communication is largely considered a transactional process defined by structural components that facilitate dissemination of the key message of the change effort. Change in complex health care environments and service delivery systems requires that occupational therapy managers additionally conceptualize communication as transformative communication and a means of deepening relationships and developing shared understanding that leads to the co-creation of new knowledge and action (Manojlovich et al., 2015). Transformative communication is especially valuable during time of uncertainty and change and enables occupational therapy managers to more effectively align goals, facilitate decision making, and support change readiness. Thomas et al. (2011) indicated that when occupational managers focus on relational engagement through the change effort through inviting, affirming, and clarifying communication practices, they facilitate dialog and the emergence of shared meaning, conceptual reframing and expansion, and the establishment of new knowledge. Change efforts are successful and innovation flourishes when shared meaning is established and new knowledge is created. Case Example 18.1 illustrates building a culture knowledge translation. 181 Review Questions 1. What key areas of occupational therapy practice may require systematic change efforts? 2. What are the characteristics of transformative communication, and how can they improve change outcomes? 3. How can the change effort life cycle enable occupational therapy managers to create a change-ready organization? SUMMARY Occupational therapy managers have the opportunity and responsibility to constantly monitor and improve services provided and advance the practice and development of organizations and staff. Ushering in change in organizations influenced by regulatory, policy, and payment reforms; increasing health care complexity and fragmentation; shifting organizational structure and governance; and changing workforce demographics and pressures require more than organizational restructure, procedural and reporting structure mandates and reporting, training, and incentives. To innovate in enterprises, organizations, and staff, occupational therapy managers must stay abreast of practice trends and stakeholder needs; evaluate and prioritize workplace and practice concerns; envision a new future and empower a leadership coalition to build urgency and commitment; and continually monitor, review, and renew. Change is inevitable, but it is also imperative. Change and innovation ensure that occupational therapy services are vital and valued, and change management ensures that change and innovation are incorporated and integrated into practice. ❖ CASE EXAMPLE 18.1. Building a Culture of Knowledge Translation in a School Setting Over the past several decades, managers and practitioners have seen an explosion in the generation, dissemination, and consumption of scientific evidence in health care. Simultaneously, health providers are serving more and more clients, addressing increasingly complex health care issues, and producing more documentation, all limiting the time available for professional development activities (Institute of Medicine [IOM], 2001). Delays in translating this knowledge into best practice within the health care setting can have a profound impact on client outcomes (Berwick, 2008). In fact, the IOM (2001) suggested that it often takes 17 years for research to be effectively translated into practice. As a result, many organizations have seen a shift in approaches to the development and implementation of continuing education in the workplace from expert-led to learner-centered training (Shojania et al., 2012). Balancing these workplace demands and mitigating the delays associated with consuming and translating evidence to practice became my focus as a program manager of a large suburban school district program of occupational therapy practitioners and physical therapy practitioners. The unique body of knowledge required of school occupational therapy practitioners is dynamic and changes rapidly with local, state, and federal regulatory changes; the advancement of scientific evidence; and the development of best practices. Yet, like most school occupational therapy practitioners in this practice setting, staff members reported that access to relevant clinical literature, ability to interpret research findings, and translation of knowledge to school teams are difficult (Laverdure, 2014). In contrast, occupational therapy practitioners reported using colleagues as a source of information and to support the uptake of new learning and teams were reporting that practice change occurred most effectively in collaborative learning contexts. Following assessment of the needs of the program and its stakeholders, I determined that creating change in evidence-based practice (EBP) and knowledge translation (KT) was going to take more than organizational restructure, training, incentives, regulation, and mandates. Occupational therapy managers and organizational leaders often serve as essential change leaders in the implementation and sustainability of EBP in the work setting (Aarons et al., 2015). Aarons and Sommerfield (2012) suggested that first-level leaders, or those who provide direct supervision of health care staff, are often essential change agents for the development of positive attitudes and for the establishment of a climate of active innovation in establishing wide-scale adoption of EBPs within organizations. They posited that through the development of a climate of acceptance, barriers to change implementation can be mitigated and overcome. Drawing from Kotter’s (2001) 8 Stages of Change and Parent et al.’s (2007) Dynamic Knowledge Transfer Capacity Model of Change Implementation, a collaborative social learning environment was established to support the development of EBP and KT. Table 18.2 illustrates the steps taken to support change in practice. (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 182 SECTION III. Navigating Change and Uncertainty CASE EXAMPLE 18.1. Building a Culture of Knowledge Translation in a School Setting (cont.) TABLE 18.2. Steps Taken to Support Change in Practice DYNAMIC KNOWLEDGE TRANSFER CAPACITY MODEL Inquiry: Building Awareness During this phase, I assessed the needs of all stakeholders and empowered the staff to use creativity and invention to achieve the goals established through the change effort. KOTTER’S 8 STAGES OF CHANGE STAGE PROGRAM ACTION Establish a sense of urgency ■ Introduced state and federal regulatory requirements and national and state standards of practice and ethical guidelines for EBP. ■ Provided training and practice examples of EBP and effective and reproducible client outcomes. ■ Provided exemplars of client (teacher and family) satisfaction and capacity outcomes. Create a guiding coalition ■ Established a small group of practice leaders, led by an identified KT Facilitator, to form a guiding coalition to identify the need for practice change and exemplified change in practice. ■ The guiding coalition collaborated with stakeholders within and outside of the program to identify the scope of the need for change in EBP and KT practices. Develop a change vision ■ Established a clear and succinct unifying vision and introduced nomenclature and strategy to support the vision. Communicate a vison for buy-in ■ The guiding coalition produced 2 evidence briefs that addressed hot topics in practice and, with the program manager, developed reflection and evidence appraisal models to support EBP and clinical reasoning in the context of CLTs. ■ Staff derived immediate benefit from the recommendations included in the practice briefs. Planning: Building Community Empower broad-based action and Competency During this phase, I networked and empowered stakeholders to build a collaborative blueprint to implement and integrate change. ■ Established 11 CLTs focused on specific practice questions. ■ Resources, training, coaching, and mentoring were provided to the CLTs and individual staff members. ■ The aims of the CLTs were linked to individual professional development goals and performance appraisal. Implementation: Building Momentum During this phase, I monitored the stages of change, the utilization of new knowledge, and the outcomes of the change effort. Generate short-term wins ■ The CLTs disseminated the results of their collaborative learning, practice outcomes, and recommendations. Don’t let up ■ As the work of the CLTs expanded and staff achieved their professional development goals, learning expanded and staff began disseminating their knowledge within and outside of the program (practice guidelines, conference presentation, and publication). Sustaining: Building Acceptance Anchor new approaches During the final phase, I established continuous improvement efforts (feedback loops, qualitative and quantitative data collection) and ensured resources to support distributed leadership. ■ The program manager evaluated the development and refinement of narrative knowledge, research literacy and utilization, and knowledge exchange/sharing practices. ■ A competency-based performance assessment process was established to evaluate staff’s accomplishment of EBP and KT professional development goals. ■ Data were analyzed and 98% of staff met the performance targets established through the change effort. ■ Plans were put in place to begin to evaluate client outcomes. Note. CLTs = collaborative learning teams; EBP = evidence-based practice; KT = knowledge translation. Review Questions 1. 2. 3. Occupational therapy practitioners often report that they most use colleagues as a source of information to support the uptake of new learning. Why is this an important consideration for occupational therapy managers who are implementing programs to increase the use of EBP? Why is designing and implementing effective practice that increase the uptake and translation of evidence to practice an important consideration for occupational therapy managers? What steps that were taken to implement and sustain EBP in a large metropolitan school system? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 18. Managing Organizational Change ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ ■ ■ ■ ■ ■ ■ ■ B.4.25. Principles of Interprofessional Team Dynamics B.4.27. Community and Primary Care Programs B.5.1. Factors, Policy Issues, and Social Systems B.5.2. Advocacy B.5.3. Business Aspects of Practice B.5.4. Systems and Structures That Create Legislation B.5.6. Market the Delivery of Services B.5.7. Quality Management and Improvement. REFERENCES Aarons, G. A., Ehrhart, M. G., Farahnak, L. R., & Hurlburt, M. S. (2015). Leadership and Organizational Change for Implementation (LOCI): A randomized mixed method pilot study of a leadership and organization development intervention for evidence-­ based practice implementation. Implementation Science, 10, 11. https://doi.org/10.1186/s13012-014-0192-y Aarons, G. A., & Sommerfield, D. H. (2012). Leadership, innovation climate, and attitudes toward evidence-based practice during a statewide implementation. 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Implementation Science, 3, 1. https://doi.org/10.1186/1748-5908-3-1 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 184 SECTION III. Navigating Change and Uncertainty Kotter, J. (2001). What leaders really do. Harvard Business Review, 79, 85–97. Laverdure, P. (2014). Considerations for the development of expert practice in school-based occupational therapy. Journal of Occupational Therapy, Schools, and Early Intervention, 7, 225–234. https://doi.org/10.1080/19411243.2014.966016 Linnell, D. (2003). Evaluation of capacity building: Lessons from the field. Retrieved from http://fundingcapacity.issuelab.org/resource /evaluation-of-capacity-building-lessons-from-the-field.html Manojlovich, M., Squires, J. E., Davies, B., & Graham, I. D. (2015). Hiding in plain sight: Communication theory in implementation science. 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Implementation Science, 8, 15. https://doi.org/10.1186/1748-5908-8-15 Shatpattananunt, B., Petpichetchian, W., & Kitrungrote, L. (2015). Development of the change implementation strategies model regarding evidence-based chronic wound pain management. Pacific Rim International Journal of Nursing Research, 19, 359–372. Shojania, K. G., Silver, I., & Levinson, W. (2012). Continuing medical education and quality improvement: A match made in heaven? Annals of Internal Medicine, 156, 305–308. https://doi .org/10.7326/0003-4819-156-4-201202210-00008 Sijpkens, M. K., Steegers, E. A., & Rosman, A. N. (2016). Facilitators and barriers for successful implementation of interconception care in preventive child health care services in the Netherlands. Maternal Child Health Journal, 20, 117–124. https://doi.org /10.1007/s10995-016-2046-5 Spaulding, A., Kash, B., Johnson, C., & Gamm, L. (2017). Organizational capacity for change in health care: Development and validation of a scale. Health Care Management Review, 42, 151–161. https://doi.org/10.1097/HMR.0000000000000096 Thomas, R., Sargent, R. D., & Hardy, C. (2011) Managing organizational change: Negotiating meaning and power-resistance relations. Organization Science, 22, 22–41. https://doi.org/10.1287/orsc.1090.0520 Valentijn, P. P., Schepman, S. M., Opheij, W., & Bruijnzeels, M. A. (2013). Understanding integrated care: A comprehensive conceptual framework based on the integrative functions of primary care. International Journal of Integrated Care, 13, e010. https://doi.org/10.5334/ijic.886 Volker, N., Williams, L. T., Davey, R. C., Cochrane, T., & Clancy, T. (2017). Implementation of cardiovascular disease prevention in primary health care: Enhancing understanding using normalisation process theory. Family Practice, 18, 1–9. https://doi.org/10.1186 /s12875-017-0580-x Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Planning During Uncertainty 19 Jaime L. Smiley, MS, OTR/L, and Thomas Smith, MBA, OTR/L LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ ■ ■ Identify health care trends leading to an environment of uncertainty, Recognize the importance of a health care organization’s mission and vision and how they affect planning, Describe the planning process involved for each of the 4 different levels of uncertainty, Describe how a rolling strategic plan is helpful during times of uncertainty, Identify the occupational therapy manager’s role in communicating the changes needed to minimize uncertainty, Identify the 4 characteristics of transformational leadership, and Describe the Lean Six Sigma methodology as a process within transactional leadership. KEY TERMS AND CONCEPTS • • • • • Alternate futures Clear-enough future Full-range leadership model Lean Six Sigma Mission • • • • Participation in decision making Range of futures Strategic planning Transactional leadership OVERVIEW Managing During Periods of Uncertainty Uncertainty can be defined as a “dynamic state in which there is a perception of being unable to assign probabilities to outcomes” (Penrod, 2001, p. 241). Because uncertainty is a dynamic concept, it can be present frequently and at various degrees of complexity in an organization. Some amount of uncertainty in decision making is nearly always present. For example, occupational therapy managers could be uncertain about such daily issues as which problems to prioritize, who to promote, or how to manage therapy referrals. More broadly, 2 health care facilities might merge, creating questions about who might be retained and who dismissed from the newly formed organization, or a governing body votes to close a state hospital in 1 of the city’s poorest communities, resulting in community outcry and legal action by hospital • • • • Transformational leadership True uncertainty Uncertainty Vision employees. In such situations, the level of uncertainty within the organization is so complex that it affects most, if not all, managerial actions. This chapter focuses on uncertainties that have a high impact on the organization and are readily apparent. This chapter explores what occupational therapy managers must do to plan, organize, and maintain order while supporting staff and administration in times of uncertainty. Because managing during times of uncertainty requires planning that has both traditional and alternative components, this chapter discusses how, in uncertain situations, focusing on the organization’s mission and vision is essential to minimize uncertainty. Additionally, leadership qualities that advance optimism, create opportunities, and provide a model for thriving despite the uncertainty are discussed. Finally, this chapter emphasizes relying on evidence from well-researched and proven methods for managing uncertainty. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.019 185 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Planning During Uncertainty 19 Jaime L. Smiley, MS, OTR/L, and Thomas Smith, MBA, OTR/L LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ ■ ■ Identify health care trends leading to an environment of uncertainty, Recognize the importance of a health care organization’s mission and vision and how they affect planning, Describe the planning process involved for each of the 4 different levels of uncertainty, Describe how a rolling strategic plan is helpful during times of uncertainty, Identify the occupational therapy manager’s role in communicating the changes needed to minimize uncertainty, Identify the 4 characteristics of transformational leadership, and Describe the Lean Six Sigma methodology as a process within transactional leadership. KEY TERMS AND CONCEPTS • • • • • Alternate futures Clear-enough future Full-range leadership model Lean Six Sigma Mission • • • • Participation in decision making Range of futures Strategic planning Transactional leadership OVERVIEW Managing During Periods of Uncertainty Uncertainty can be defined as a “dynamic state in which there is a perception of being unable to assign probabilities to outcomes” (Penrod, 2001, p. 241). Because uncertainty is a dynamic concept, it can be present frequently and at various degrees of complexity in an organization. Some amount of uncertainty in decision making is nearly always present. For example, occupational therapy managers could be uncertain about such daily issues as which problems to prioritize, who to promote, or how to manage therapy referrals. More broadly, 2 health care facilities might merge, creating questions about who might be retained and who dismissed from the newly formed organization, or a governing body votes to close a state hospital in 1 of the city’s poorest communities, resulting in community outcry and legal action by hospital • • • • Transformational leadership True uncertainty Uncertainty Vision employees. In such situations, the level of uncertainty within the organization is so complex that it affects most, if not all, managerial actions. This chapter focuses on uncertainties that have a high impact on the organization and are readily apparent. This chapter explores what occupational therapy managers must do to plan, organize, and maintain order while supporting staff and administration in times of uncertainty. Because managing during times of uncertainty requires planning that has both traditional and alternative components, this chapter discusses how, in uncertain situations, focusing on the organization’s mission and vision is essential to minimize uncertainty. Additionally, leadership qualities that advance optimism, create opportunities, and provide a model for thriving despite the uncertainty are discussed. Finally, this chapter emphasizes relying on evidence from well-researched and proven methods for managing uncertainty. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.019 185 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 186 SECTION III. Navigating Change and Uncertainty ESSENTIAL CONSIDERATIONS Rapid Health Care Change Health care is constantly changing, and the rate and number of changes are rapidly rising (Johnson, 2016). Collectively, changing national demographics, escalating health care costs, and the lack of access to health care services served as catalysts to the rapid changes we have been experiencing with ensuing uncertainty within our health care industry. Health care organizations and providers find themselves implementing anticipatory and adaptive changes as a means to better meet the needs of customers. Excessive change is becoming normal practice in the health care industry. Any health care organization must respond to external factors. Systems, institutions, and populations impose change and can create and maintain a state of uncertainty. For example, regulatory and reimbursement overhauls can be imposed by payers at any time, challenging to an organization that is pressured to be fiscally responsible while continuing to ensure positive clinical outcomes and find ways to improve its operation. Despite spending more money on health care than other industrialized countries, the U.S. health care industry does not produce the same outcomes as its international peers. In 2016, the United States spent twice as much on health care services than countries such as Canada, the United Kingdom, and Japan while achieving worse health and access outcomes (Papanicolas et al., 2018). In addition, the U.S. population is aging. In 2014, 15% of the total U.S. population was age 65 years or older. By 2030, the number of older Americans is expected to grow to nearly 21% of the U.S. population (Federal Interagency Forum on Aging Related Statistics, 2016). Proportionately fewer people will be paying into Medicare, jeopardizing the solvency of that program. This is particularly disconcerting because people age 65 years or older consume the most health care services. This alone creates uncertainty. Managing against this backdrop of rapid and continued change, health care organizations and occupational therapy managers might consider asking how, in an environment of increasing numbers of older adults, decreasing payment sources, and limited access to services, can we provide accessible health care at an affordable cost, and what services should be provided? Levels of Uncertainty Uncertainty is a term heavily examined across many industries when considering strategic planning and operations management. Allied health, psychology, sociology, business, and nursing consider uncertainty when assessing need and planning for change. Recall the early definition of uncertainty, which indicates a perceived inability to gauge probabilities to predict outcomes. From an organizational standpoint, this definition reflects operational and clinical decisions and the unknowns that can be imposed by external factors, such as third-party payers or regulatory bodies. The definition also reflects uncertainty relating to internal organizational factors, such as restructuring. Clients, patients, and families also have varying levels of uncertainty regarding personal care and the future of health care and their access to it. Courtney et al. (1997) identified 4 levels of uncertainty, providing a framework that will lead to better decision making during planning: (1) clear-enough future, (2) alternate futures, (3) range of futures, and (4) true uncertainty. No framework can remove all of the challenges associated with uncertainty, but an organized system for examining uncertainty will help facilitate a more informed process. Level 1. Clear-enough future At the clear-enough future level of uncertainty, a single foreseeable future is clearly enough defined to develop a strategy. It is impossible to know all variables in decision making, but this level forecasts a single option for the future after research is completed. For example, if an occupational therapy manager is experiencing a high level of turnover in the department, should the manager develop better communication skills? Is there a problem with the salary or benefits package? Are therapists not properly trained and provided with orientation to department policies and procedures? After examining all of these scenarios, the manager can develop a strategy to improve retention in the therapy department. Because of this element of insight (i.e., the need for a reduction in staff turnover and a more stable workforce over a longer period of time) into an otherwise unforeseeable future, managers can use standard strategies to guide decision making. Market research, cost analysis, and examination of the organization’s internal SWOT analysis (strengths and weaknesses and external opportunities and threats) are examples of such strategies. Level 2. Alternate futures In Level 2, alternate futures indicate several possible outcomes exist. These 2 or 3 possible outcomes are clear and distinct, but it is impossible to predict which will occur. This type of uncertainty is often seen when working through potential regulatory or reimbursement changes. Consider the skilled nursing industry (SNF) in the 1990s. Prior to 1998, that industry was reimbursed on a fee-for-service schedule. When proposals for changing this reimbursement structure to managed care emerged, providers began preparing for a future that would either continue business as usual or drastically change reimbursement to a prospective payment system. Changing reimbursement models would affect every aspect of the business from service delivery to documentation and staffing, so planning during this time resulted in establishing a plan for each scenario. Level 2 strategies are more complex than Level 1 because of the multiple futures forecasted. It is imperative for leaders to identify the most probable future state through a data-driven approach and understand the implications for their organization or work force. Strategies should be implemented accordingly and monitored. If the developed strategies do not produce the intended outcome, alternative strategies should be implemented. Implemented strategies that prove to be successful should continue to be monitored for sustainability. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 19. Planning During Uncertainty 187 Level 3. Range of futures Review Questions A range of futures indicates that there is a continuum of possibilities for the future. Unlike Level 2 in which distinct options exist, Level 3 includes a range of future possibilities. Organizations looking to expand services into a new geographic area or health care environment often face this level of uncertainty. For example, consider a contract company that is looking to expand business into another state. Research into the available market and need for therapy services would indicate a range of need. Although the range is finite, the true future can be anywhere within that range. Therefore, it is impossible to predict the exact staffing, space, and equipment that will be needed. To plan at Level 3 uncertainty, managers must predict distinct futures that are the most likely to occur within the range of options. To accomplish this, managers can use planning strategies used in Levels 1 and 2 decision making for each identified probable option. It can be difficult to predict and plan for the full range of futures, but with experience and strategic planning, managers can gauge what is most probable to occur. 1. Describe changes in the overall health care system that have led to greater uncertainty over an extended period of time. 2. How do the levels of organizational uncertainty progress? How is uncertainty different at Level 1 and Level 4? Level 4. True uncertainty In Level 4 multiple variables interact to create a future that is truly unpredictable, termed true uncertainty. Within this level of uncertainty, so many variables and potential outcomes exist that no one can predict what changes are likely to occur and what their effects might be. In Level 3, managers can determine a range of possibilities, but true uncertainty in Level 4 indicates that it is still not possible to determine even a range of futures. For example, multiple and constantly emerging technologies combine to develop artificial intelligence. There are vast uncertainties about how to implement, disseminate, and regulate such technologies. This level of uncertainty in health care has rarely existed in the past but is being seen more frequently. The utilization of robotics is becoming more prevalent in the field of physical medicine as it theoretically offers more precise movement patterns and more repetitions required for progress. Despite the lack of research supporting the true efficacy of robotics in recovery, many hospitals are investing significant capital in this technology. Those investing in this technology believe that early entry can differentiate them from other providers. Those who do not take a wait-and-see approach at the expense of late entry and potential market loss. Because of the paralyzing effect of Level 4 uncertainty, industries avoid reaching this level by developing regulatory and governing stability to allow for decisions to be made at Levels 1, 2, or 3. However, despite the best planning efforts, Level 4 uncertainty can and does occur. Planning at Level 4 is not necessarily targeted at making decisions but focuses instead on systematically obtaining information through consultation with other organizations, clarification with policy makers, examination of literature, and ongoing analysis of the meaning and impact of the change, to gain perspective on possible strategies for the future. PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Overview of Strategic Planning Strategic planning is the process of deciding what objectives to pursue during a future time period and what to do to achieve those objectives (Rue & Byars, 2000). One of the primary roles of occupational therapy managers is to develop and implement plans. These plans can affect therapy service delivery alone, or they may be part of larger strategic plans for a hospital system, company, or other health care agency. Strategic planning is influenced by an organization’s culture, leaders, size, activities, mission and vision, and degree of urgency felt for change (Strickland, 2010). Managers must plan even when uncertainty pervades. Strategic planning is a key method for managing uncertainty because it allows the occupational therapy managers and practitioners to emphasize the more reliable aspects of an organization and its programs (i.e., certainties). It offers an opportunity to create if–then alternatives to various futures and prepare for the most likely outcomes of the period of uncertainty. Finally, strategic planning sets a reasonable timeline and takes into account what it is likely to be achieved under the uncertain conditions. Although it is beneficial to use known and familiar strategies when managing uncertainty, traditional approaches may not always work. Traditional methods of planning, organizing, and overseeing operations have a relatively linear approach. Steps to traditional methods of planning include ■ Examining where the company or organization is now. ■ Considering where the company or organization wants to be. ■ Developing a plan: • Deciding on steps needed to achieve the plan, • Fitting the plan into a traditionally identified timeframe (e.g., 5 years), and • Identifying barriers. ■ Implementing the plan. ■ Measuring outcomes. ■ Adjusting the plan as needed. In the constantly changing health care industry in which there is a high level of uncertainty, these steps may not be sufficient. Instead, occupational therapy managers must be constantly prepared for change and ready to take a more flexible approach to implementing a plan and analyzing its outcomes. In times of uncertainty, the planning process must consider how the organization can more rapidly take in and process information, adjust assumptions, build models, and Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 188 SECTION III. Navigating Change and Uncertainty recalculate expectations. Leaders must quickly come to a full understanding of the planning models being used so they can question assumptions, make rapid alterations in the plan as needed, and guide their teams to implement necessary changes. Rather than develop a strategic plan in the traditional linear fashion, occupational therapy managers may need to use a “rolling” strategic planning process, which allows for regularly refreshing the plan as uncertainties continue to develop and until a more certain path can be identified (Jacobs & Ursitti, 2017). When creating a strategic plan during uncertainty, managers must move forward with several factors still unknown. They communicate to staff that they recognize and acknowledge that right now there is not enough time to develop comprehensive plans for every possibility, nor can they wait to take action until all regulatory information is provided, learned, and processed. To successfully plan during uncertainty, management must be able to take unknowns into consideration, accept their inability to control those aspects of the plan, and focus on what is achievable while continuing to explore ways to minimize the uncertainties. The establishment of defined metrics associated with the strategic plan provides a mechanism to evaluate the efficacy of implemented tactics. Decisions to sustain current efforts or to alter one’s course are driven by the organizational performance related to these metrics. Outcomes that do not meet expected metrics may indicate that the strategic plan may need to be refreshed. Determining Rationale them (Jacobs & Ursitti, 2017). It is essential that a planning team fully understand and embrace the organization’s mission and vision. It is equally important that managers clearly communicate how the mission and vision influenced decision making and planning. If all members do not understand the mission and vision, or how decisions reflect the mission and vision, there may be less buy-in and acceptance of new initiatives and goals. Research and Information Gathering When managing during times of uncertainty, using well-­ researched information from reputable sources is imperative because it adds to a sense of security and verification. Focusing on known and familiar strategies and how they relate to an organization’s current situation demonstrates to stakeholders previously trod paths for emerging from times of uncertainty; it allows managers to learn from what others have done in the past. Furthermore, when the organization acknowledges that it is less knowledgeable on crucial issues, it provides some assurance to stakeholders that it is actively engaged in information gathering to solve the problem. Such action can reduce anxiety and fosters a feeling that despite current uncertainties, solutions are forthcoming. For example, actions like monitoring local markets, considering new regulations, exploring new service delivery models and technologies, and learning from competitors while remaining true to the organization’s mission and vision can demonstrate how the organization is invested in solving problems (Jacobs & Ursitti, 2017). When determining whether a change will occur, it is important to assess the rationale for change. Are there external changes occurring that require organizational changes to continue to thrive in the market? Are there internal systems that need to be revised so the organization can continue to thrive? Before the planning process can begin, this rationale must be determined. When approaching this change, an understanding of how change will continue to occur through the planning process is important. This constant change must be expected and embraced during the planning process. Engaging Staff Upholding Mission and Vision Understand staff perceptions A vision describes a projection toward the organization’s desired future. A mission describes the organization’s longterm purpose and role. Having a clear mission and vision statement is particularly important during periods of uncertainty because these statements are designed to describe the organization’s long-term purpose and role and therefore represent 1 of the most basic and fundamental certainties of the organization. The mission answers the question, Why does the organization exist? The vision answers the question, Where is the organization going? When planning in times of uncertainty it is important for each person involved in the planning process to fully understand both the mission and vision, to keep this information readily available for reference, and to ensure decisions reflect To build a strong strategic plan during uncertainty, managers must carefully explore employees’ concerns about their futures in the organization, their sense of how an uncertain situation arose, and the impact it will have on themselves and the organization as a whole (Cullen et al., 2014). Managers must consider the employees’ perception of change and disposition toward change. Employees’ perceptions of and attitudes toward the uncertainty and the changes proposed to minimize it correlate with their understanding of the situation and how changes affect them (Lau & Woodman, 1995). Therefore, it is the leadership’s responsibility to clearly describe what events and conditions created the uncertainty, clarify the rationale for change, and provide the objectives of the change initiative and how change will be measured. Broad changes in the health care industry yield uncertainty in the work environment and can greatly affect employee engagement, alignment, and performance (Rafferty & Griffin, 2006). Hallmark characteristics of uncertainty are a sense of doubt about future events and confusion over the exact cause and effect relationships in the environment that are causing the problems that require change (DiFonzo & Bordia, 1998). Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 19. Planning During Uncertainty Companies value employees who recognize the importance of change, understand the value of altering personal expectations within a newly forming paradigm, and can capitalize on opportunities despite current uncertainty. Employees who can be creative in exploring critical areas for personal and organizational success are considered valuable members of the team (Ngo & Loi, 2008). For example, it is critical for employees to have buy-in in an era of payment reform that rewards quality care and an enhanced patient experience. When employees perceive strong organizational support, they are more likely to feel that their social–emotional needs are being met and to report more positive job satisfaction and organizational engagement. Conversely, lack of organizational support, especially from a direct manager, may have a deleterious impact on the organization. This is especially true during times of uncertainty. Communication Employee uncertainty often occurs because of missing or failed communication between leadership and staff. This uncertainty may lead to stress, decreased job satisfaction, and employee turnover. Inadequate communication regarding the organization’s vision for the change is one of the main reasons why organizational change fails (Kotter, 1995). As Jiang and Probst (2014) illustrated in a study on organization communication, effective communication serves as a useful strategy to minimize stress associated with uncertainty. Through clear communication about the reasons for uncertainty, occupational therapy managers can engage staff and reduce some of the associated stress. Open dialogue not only offers a better understanding of what is causing uncertainty but also provides the transparency required for the team to develop confidence and trust in leadership. Managers openly and transparently communicating with staff is a key strategy to reduce employee uncertainty during times of change (Lewis, 1999; Tanner & Otto, 2017). Participation in decision making Perceptions that an organization is supportive of its employees have been shown to explain how some workers positively adapt to the uncertainty and associated changes, ultimately experience greater job satisfaction, and display better job performance (Cullen et al., 2014). Participation in decision making (PDM) is the process by which influence or decision-making is shared between supervisors and employees (Sagie et al., 1995). Bordia et al. (2004) showed that management communication reduces strategic uncertainty. To reduce structural and job-related uncertainty, it is imperative to fully integrate PDM and 2-way communication. Organizations that make an effort to communicate with employees may reduce the negative consequences of organizational change and job insecurity (Jiang & Probst, 2014). Engagement of employees in the change initiative can provide a sense of control to help with the emotional toll of uncertainty. 189 Leadership Skills for Uncertain Conditions It is human nature to have an aversion to uncertainty; people desire a degree of certainty. Being able to anticipate one’s daily schedule, the content on the next exam, or one’s career path goes a long way in relieving stress in our lives. Uncertainly disrupts our sense of control and can lead to unwanted stress. Skilled occupational therapy managers and leaders can assist staff and the organization to manage the stress of uncertainty and to adapt responsibly to a dynamic environment. Although several leadership models may be referenced to assist with organizational change, the full-range leadership model is a validated approach offering a blend of leadership styles to support and sustain change within an organization (Bass & Avolio, 1990; Judge & Piccolo, 2004). The model identifies essential leadership behaviors within 2 primary dimensions: (1) transformational and (2) transactional. Both forms of leadership are required of managers when supporting organizational change. Transformational leadership is important for developing a climate for innovation and positive attitudes toward evidence-based practice during change implementation initiatives (Aarons & Sommerfeld, 2012). First-level leadership (i.e., front-line leadership, or direct leaders of patient care employees) is critical to the transformational process. More positive first-level leadership is associated with more positive provider attitudes toward adopting evidence-based practices (Aarons, 2006). Transformational leadership Transformational leadership is the degree to which a leader can inspire and motivate others to follow an ideal or a particular course of action (Bass, 1999). It is comprised of 4 components that influence organizational change and have been shown to lead to positive behaviors in organizations: 1. Individualized consideration: Appreciation of each staff member’s contributions and needs, 2. Intellectual stimulation: Ability to stimulate thinking and accept different ideas or perspectives, 3. Inspirational motivation: Ability to inspire and motivate staff, and 4. Idealized influence: Degree to which leaders act confidently, and instill pride, respect, values, beliefs, and a strong sense of purpose (Bass & Avolio, 1990). Transactional leadership Transactional leadership is the degree to which a manager focuses on the processes involved in achievement through use of quality standards, incentives, and rewards. This type of leadership also penalizes negative performance when necessary. Transactional leadership focuses on organizational processes and policies to assure optimal outcomes. Transactional leaders clearly delineate goals and objectives for the organization so all employees have specific targets to reach. Achievement of goals and objectives warrants rewards, and failure to achieve them results in penalties. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 190 SECTION III. Navigating Change and Uncertainty Strong transactional leaders work to create processes that avoid penalties and motivate workers to achieve rewards, thereby improving the delivery of health care services. Although there are various ways to achieve established process objectives from a transactional leadership perspective, the Lean Six Sigma philosophy provides a data-driven methodical approach to enhancing performance. Using transactional leadership, the approach emphasizes “lean” processes for eliminating waste and ensuring added value and processes for reducing variation in service delivery. This 5-step process (define, measure, analyze, improve, control) allows an organization to better understand current processes, identify opportunities for improvement, and use data to objectively measure the effects of imposing change. Lean Six Sigma is a pragmatic approach that attempts to reduce variation in the delivery of services by eliminating waste and defects while establishing more effective processes (Courtney et al., 1997). Review Questions 1. How does planning under uncertain conditions differ from traditional strategic planning processes? 2. Why are the mission and vision of the organization essential to planning during times of uncertainty? 3. What can occupational therapy managers do to reduce the negative impact of uncertainty felt by employees? CASE EXAMPLE 19.1. Payment Methodology Adaptation Indication of impending large-scale changes in federal payment models based on U.S. congressional health care legislation threatened to drastically alter reimbursement and led to uncertainty about how plan for the future in the skilled nursing industry and other areas of rehabilitation, including inpatient services, like at the Acme Nursing and Rehabilitation Center. How best to prepare for the wide range of possible alterations in current procedures depended on finalized specifications from the Centers for Medicare and Medicaid Services (CMS), but those details were not fully available to the management team at Acme. Managers were also aware that such changes typically required interpretation and clarification before a final plan could be created. Although uncertainties abounded, delays in taking action would affect Acme’s funding. This, in turn, could affect the quality of services delivered and Acme’s overall operation and planning. Managers at Acme knew that they had prepared with various scenarios so they would be ready to rapidly implement organizational changes to avoid loss of funding once CMS released changes in federal policies regarding payment. Management appropriately regarded this uncertainty as a Level 3 because it could anticipate a range of possible strategies as solutions but were unable to narrow them down to very few solutions until further information was obtained. Therefore, managers began to develop a set of alternative strategies, a combination of which would depend upon final decisions by the CMS. The planning strategy consisted of the following actions: ■ ■ ■ ■ ■ ■ Acme’s top management team assembled to initiate a plan. This team consisted of chief executive, operations, and financial officers and the leaders of all major departments, including nursing, occupational therapy, physical therapy, speech–language pathology, and social work. The chief executive officer began with a full review of Acme’s mission and vision, assuring everyone that the mission and vision remained the foundation of the organization and that changes would be implemented to sustain them. Reliable information was gathered from national associations that maintain connections with federal legislators and policy makers. These included the American Health Care Association; the American Rehabilitation Providers Association; and all professional health care associations, including the American Occupational Therapy Association (AOTA). Managers also consulted with reliable colleagues from other health care organizations to discover issues they had not yet considered. The management team scrutinized the reliability and sincerity of everyone with whom they consulted. In 1 case, it became apparent that a software vendor was taking advantage of the present uncertainties to benefit his own company at the cost of Acme. The management team reconvened to analyze and interpret the gathered information and refine initial plans. The team developed a proposal for how Acme would make changes. At this point, management felt they had more knowledge and understanding of the proposed policy changes and clearer options for how to manage them. Team members felt they had narrowed their Level 3 uncertainty and were closer to but not squarely at Level 2. As information was being gathered and interpreted, clinical managers, including the occupational therapy manager, were instructed to inform staff of impending changes in payment policies. Chief management offered their assistance to clinical managers in describing the current situation, easing concerns, motivating and empowering staff, and ensuring that daily operations would continue unimpeded as much as possible. The use of transformational leadership skills was essential at this stage of the planning process. Among other communications, managers assured staff that therapies would not be contracted to outside agencies and that the current “in-house” model would remain intact, as rumors had spread that outsourcing might be necessary. On the basis of information obtained from several sources, Acme could narrow its plan to 2 alternative strategies they were likely to use, depending on final CMS decisions. When the final decision was announced, the management team put a plan into action that required a reduction in group therapies and concurrent treatments, and a plan for follow-up on all discharged clients to monitor the impact of treatment on recidivism, community engagement and health, and acquisition of durable medical equipment and medications. Transactional leadership through use of the Lean Six Sigma method was essential at this stage of management. Review Questions 1. 2. 3. How did management of a SNF organization determine the level of uncertainty about proposed payment-related changes? What were the responsibilities of the occupational therapy manager during the Level 3 phase of uncertainty? How did management conduct strategic planning during this time of uncertainty? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 19. Planning During Uncertainty SUMMARY Planning during times of uncertainty is a unique challenge to an organization and its managers. Given current trends in health care, it is likely that uncertainty will always be a component that management will be challenged to deal with. As the need for high quality health care grows and the demand to control its cost remains essential, an uncertain future for the health care industry seems prevalent. Therefore, health care organizations and the clinical departments within them must prepare viable options to business plans and operations to ensure success. To do so, clinical managers, including occupational therapy managers, must work with staff to maintain the mission and vision of the organization. They must use both transformational and transactional leadership skills to motivate staff to work toward desirable outcomes and assure organizational processes continue unimpeded. This can be accomplished through use of rewards and incentives for ongoing excellence and, when necessary, by imposing penalties. It is important to identify the type of uncertainty the organization is facing. Proper planning and inclusion of employees in part of the decision-making process will help reduce stress and anxiety regarding upcoming changes. Two-way communication is critical when discussing the upcoming changes in an organization. During the planning process, thorough information gathering and being able to disseminate needed information will help guide plans. Standard strategic planning methods do not always work when planning during uncertainty. ❖ ACOTE STANDARDS This chapter addresses the following ACOTE Standards: ■ B.4.18. Grade and Adapt Processes or Environments ■ B.5.1. Factors, Policy Issues, and Social Systems ■ B.5.3. Business Aspects of Practice. REFERENCES Aarons, G. A. (2006). Transformational and transactional leadership: Association with attitudes toward evidence-based practice. Psychiatric Services, 57, 1162–1169. https://doi.org/10.1176 /appi.ps.57.8.1162 Aarons, G. A., & Sommerfeld, D. H. (2012). Leadership, innovation climate, and attitudes toward evidence-based practice during statewide implementation. Journal of the American Academy of Child and Adolescent Psychiatry, 51, 423–431. https://doi.org /10.1016/j.jaac.2012.01.018 Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72, 7212410005. https://doi.org/10.5014 /ajot.2018.72S217 Bass, B. M., & Avolio, B. J. (1990). The implications of transactional and transformational leadership for individual, team, 191 and organizational development. Research in Organizational Change and Development, 4, 231–272. Bass, B. M. (1999). Two decades of research and development in transformational leadership. European Journal of Work and Organizational Psychology, 8, 9–32. https://doi.org/10.1080/135943299398410 Bordia, P., Hobman, E., Jones, E., Gallois, C., & Callan, V. J. (2004). Uncertainty during organizational change: Types, consequences, and management strategies. Journal of Business and Psychology, 18, 507–532. https://doi.org/10.1023/B:JOBU .0000028449.99127.f7 Courtney, H., Kirkland, J., & Viguerie, P. (1997). Strategy under uncertainty. Harvard Business Review. Retrieved from https://hbr .org/1997/11/strategy-under-uncertainty Cullen, K. L., Edwards B. D., Camron C. W., & Gue, K. R. (2014). Employees adaptability and perceptions of change-related uncertainty: Implications for perceived organizational support, job satisfaction, and performance. Journal of Business Psychology, 29, 269–280. https://doi.org/10.1007/s10869-013 -9312-y DiFonzo, N., & Bordia, P. (1998). A tale of two corporations: Managing uncertainty during organizational change. Human Resource Management, 37, 295–303. https://doi.org/10.1002 /(SICI)1099-050X(199823/24)37:3/4%3C295::AID-HR M10 %3E3.0.CO;2-3 Federal Interagency Forum on Aging Related Statistics. (2016). 2016 older Americans key indicators of well-being. Retrieved from https://agingstats.gov/docs/LatestReport/Older-Americans-2016 -Key-Indicators-of-WellBeing.pdf Jacobs, L., & Ursitti, T. (2017). Strategic planning amidst uncertainty: 10 considerations for health execs. Managed Healthcare Executive. Retrieved from http://www.managedhealth careexecutive.com/managed-hea lt hcare-executive/news /strategic-planning-amidst-uncertainty-10-considerations -health-execs Jiang, L., & Probst, T. M. (2014). Organizational communication: A buffer in times of job insecurity? Economic and Industrial Democracy, 35, 557–559. https://doi.org/10.1177/0143831X13489356 Johnson, K. J. (2016). The dimensions and effects of excessive change. Journal of Organizational Change Management, 29, 445–459. https://doi.org/10.1108/JOCM-11-2014-0215 Judge, T. A., & Piccolo, R. F. (2004). Transformational and transactional leadership: A meta-analytic test of their relative validity. Journal of Applied Psychology, 89, 755–768. https://doi.org /10.1037/0021-9010.89.5.755 Kotter, J. (1995). Leading change: Why transformation efforts fail. Harvard Business Review, 73, 59–67. Lau, C.-M., & Woodman, R. W. (1995). Understanding organizational change: A schematic perspective. Academy of Management Journal, 38(2), 537–554. https://doi.org/10.5465/256692 Lewis, L. K. (1999). Disseminating information and soliciting input during planned organizational change. Management Communication Quarterly, 13(1), 43–75. https://doi.org/10.1177 /0893318999131002 Ngo, H.-Y., & Loi, R. (2008). Human resource flexibility, organizational culture and firm performance: An investigation of multinational firms in Hong Kong. International Journal of Human Resource Management, 19(9), 1654–1666. https://doi.org/10.1080 /09585190802295082 Papanicolas, I., Woskie, L. R., & Jha, A. K. (2018). Health care spending in the United States and other high-income countries. JAMA, 319, 1024–1039. https://doi.org/10.1001/jama.2018.1150 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 192 SECTION III. Navigating Change and Uncertainty Penrod, J. (2001). Refinement of the concept of uncertainty. Journal of Advanced Nursing, 34, 238–245. https://doi.org/10.1046/j.1365 -2648.2001.01750.x Rafferty, A. C., & Griffin, M.A. (2006). Perceptions of organizational change: A stress and coping perspective. Journal of Applied Psychology, 91, 1154–1162. https://doi.org/10.1037/0021-9010.91.5.1154 Rue, L.W., & Byars, L.L. (2000). Management: Skills and application (9th ed.). Boston: Irwin/ McGraw-Hill. Sagie, A., Elizur, D., & Koslowsky, M. (1995). Decision type, participative decision making (PDM), and organizational behavior: An experimental simulation. Human Performance, 8, 81–94. https://doi.org/10.1080/08959289509539858 Strickland, R. (2011). Strategic planning. In K. Jacobs, & G. L. ­McCormack (Eds.), The occupational therapy manager (5th ed., pp. 103–112). Bethesda, MD: AOTA Press. Tanner, G., & Otto, K. (2016). Superior–subordinate communication during organizational change: Under which conditions does high-quality communication become important? International Journal of Human Resource Management, 27, 2183–2201. https://doi.org/10.1080/09585192.2015.1090470 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Handling Resistance During Change 20 Albert E. Copolillo, PhD, OTR/L, FAOTA, and Dianne F. Simons, PhD, OTR/L, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ ■ Understand the reasons that workers resist change, Describe resistance to change in terms of the 6 basic needs of workers, Describe predispositions to negative resistance to organizational change, Recognize indirect responses and direct challenges to proposed change, Identify the managerial responsibilities and challenges to change resistance, and Describe managers as role models for change and reliance on superiors to manage change resistance. KEY TERMS AND CONCEPTS • Change • Competence • Control • Inclusion/connection • Justice/fairness • Power • Resistance to change • Security OVERVIEW ESSENTIAL CONSIDERATIONS orkers can experience emotional reactions when changes occur in the systems, departments, and programs of the organizations in which they work. This chapter provides underlying reasons that workers resist change by examining the characteristics of the change, the basic needs of workers, and predispositions to negative resistance to change. The need for occupational therapy managers to recognize, analyze, and respond to workers’ perceptions about a proposed change is discussed. This chapter also provides strategies for creating a work environment that welcomes change and for effectively creating change even when negative resistance is present. Resistance to change is examined and analyzed from both the perspective of the occupational therapy manager and the employees. (We acknowledge that there are reasonable and acceptable rationales for resisting change but that some resistance is based on limited perspectives.) Why Resist? Amount, Intensity, and Time Aspects of Change W Change is means to creating a difference. It can involve moving from a relatively steady state into a place of uncertainty, followed by a new state of equilibrium. We frequently use modifiers when describing change (e.g., “organizational change”) to identify the environment the change is intended to affect. Emotional reactions and change are seen as inseparable from change in many organizational change theories. People may view change as promising, threatening, or simply inevitable, but all workers have opinions and reactions to change (Anderson & Anderson, 2010b; Dasborough et al., 2015; Lindebaum & Jordan, 2012). People’s reactions to change are related to perceptions of the number of changes they are expected to make (i.e., amount), the impact the change will have on the way they Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.020 193 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER Handling Resistance During Change 20 Albert E. Copolillo, PhD, OTR/L, FAOTA, and Dianne F. Simons, PhD, OTR/L, FAOTA LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ ■ ■ ■ ■ ■ Understand the reasons that workers resist change, Describe resistance to change in terms of the 6 basic needs of workers, Describe predispositions to negative resistance to organizational change, Recognize indirect responses and direct challenges to proposed change, Identify the managerial responsibilities and challenges to change resistance, and Describe managers as role models for change and reliance on superiors to manage change resistance. KEY TERMS AND CONCEPTS • Change • Competence • Control • Inclusion/connection • Justice/fairness • Power • Resistance to change • Security OVERVIEW ESSENTIAL CONSIDERATIONS orkers can experience emotional reactions when changes occur in the systems, departments, and programs of the organizations in which they work. This chapter provides underlying reasons that workers resist change by examining the characteristics of the change, the basic needs of workers, and predispositions to negative resistance to change. The need for occupational therapy managers to recognize, analyze, and respond to workers’ perceptions about a proposed change is discussed. This chapter also provides strategies for creating a work environment that welcomes change and for effectively creating change even when negative resistance is present. Resistance to change is examined and analyzed from both the perspective of the occupational therapy manager and the employees. (We acknowledge that there are reasonable and acceptable rationales for resisting change but that some resistance is based on limited perspectives.) Why Resist? Amount, Intensity, and Time Aspects of Change W Change is means to creating a difference. It can involve moving from a relatively steady state into a place of uncertainty, followed by a new state of equilibrium. We frequently use modifiers when describing change (e.g., “organizational change”) to identify the environment the change is intended to affect. Emotional reactions and change are seen as inseparable from change in many organizational change theories. People may view change as promising, threatening, or simply inevitable, but all workers have opinions and reactions to change (Anderson & Anderson, 2010b; Dasborough et al., 2015; Lindebaum & Jordan, 2012). People’s reactions to change are related to perceptions of the number of changes they are expected to make (i.e., amount), the impact the change will have on the way they Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.020 193 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 194 SECTION III. Navigating Change and Uncertainty perform expected work tasks (i.e., intensity), and the time frame they are given to create the change. The time available to react to and implement a change will be weighed against the perceived quantity of changes needed to be made and the qualities of the expected tasks in relation to those of the current work activities. A worker will judge the proposed change by asking the following questions: ■ Amount: How much do I need to alter the way I currently ■ ■ do things? Overall, does the change mean more or less work for me and my coworkers? Does the change reduce or increase the amount of work I am most likely to do or that I least prefer? Will the number of tasks and the balance between most and least preferred work tasks be significantly altered? Intensity: Are the characteristics of the new expectations substantially different from how I currently do my job? Do they require new learning and a different focus, that is, do I need to develop new knowledge, skills, and abilities to work within the changed expectations and environment? Time: How much time do I have to make these adjustments? Can the changes be implemented gradually over time, or will they have to take place all at once? Can I meet proposed deadlines? If workers conclude that the amount, intensity, and time factors involved in the change are acceptable, then emotional reactions to change are more likely to be positive, and managers are more likely to receive cooperation, feedback, and suggestions meant to improve the change and change process and to facilitate a smoother transition to a new system or procedure. However, if workers feel that any component of the change (i.e., amount, intensity, time) is unreasonable or unachievable, then the manager is likely to sense a degree of discontent, less cooperation, and difficulties in the process of implementing the change or to encounter outright resistance to it. Both the positively focused feedback and suggestions and the negative undertones constitute resistance to change. Basic Needs of Workers Anderson and Anderson (2010b) present 6 basic needs as part of a theory of the individual worker’s perspective on resistance to change: 1. Security is the feeling that the change will either create or maintain physical and emotional safety. Job security is the primary concern of workers when major organizational changes are proposed. However, a firm sense of identification with the organization and its procedures also creates security, which can be threatened during times of change (Elstak et al., 2015). 2. Inclusion/connection is a sense that an individual is invited to participate in the change process and that their views are welcomed. The feeling that someone might become less a part of the organization or that their views are less appreciated than they have been can result in resistance to the change. 3. Power is ability to influence the change and its process, at least at the individual level. The potential for loss of influence and authority may lead to resistance. 4. Control is a sense of organization and predictability about the change. A loss of the sense of structure in work routines and an inability to predict what one will be expected to do can lead to resistance. Feeling that one has no choice but to resign to an unwanted change may also lead to negative resistance. 5. Competence is the feeling of being capable, skilled, and effective and the awareness that others recognize those characteristics in you. Workers are likely to resist any change perceived to reduce their capabilities; minimize the importance of their knowledge, skills, abilities, and experience; or be seen as less capable. 6. Justice/fairness is the feeling of being treated equitably; the absence of favoritism and bias. Strong feelings that the change is unfair or unjust or inequitably applied may lead to active resistance (Lind & van den Bos, 2002). Extremes in any of these 6 needs can lead to negative actions. Absences and resignation may begin to increase, and reductions in the quality and amount of work may also become apparent. In rare cases, intentional sabotage of the change may also occur as a way to resist what is perceived to be unjust, a total loss of voice, or a severe devaluing of contributions. Predisposition to Negative Resistance Emotional responses to change, including resistance, are generally viewed in terms of characteristic reactions within a specific context, not as the manifestation of personality traits (Frese et al., 2007). However, negative experiences in previous work and other life situations may predispose individuals to react to change with negative resistance. For example, a worker who feels she has been treated unfairly (i.e., affecting the need for justice/fairness), or who, despite considerable skill, efficiency, and productivity, has felt that her current or previous supervisors have not recognized those characteristics (i.e., affecting the need for competence) may demonstrate negative resistance when a proposed change poses similar threats. In general, changes leading to feelings of negative selfefficacy can lead to cynicism toward change and may result in negative resistance (DeCelles et al., 2013; Fugate et al., 2012). An occupational therapy practitioner who had confidence in the work she performed might anticipate a reduced sense of self-efficacy when considering a newly proposed method for performing job duties that might, in turn, foster resistance to the change. In contrast, a historically positive orientation to change may predispose a person to approaching proposed changes from a more optimistic perspective (Frese et al., 2007). Organizational theories of change indicate that when workers feel a sense of control and self-efficacy in the workplace, they have positive attitudes and greater investment in Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 20. Handling Resistance During Change change and efforts to successfully implement it (Fugate et al., 2012). Additionally, workers frequently make decisions based on their commitment to and investment in the organization itself (Jacobs & Keegan, 2016). Managerial Responsibilities and Challenges Creating change, managing resistance, and avoiding negative resistance to it are among the most challenging responsibilities of managers. Managing change requires creativity, collaborative planning, active listening, analysis of the purpose and expected outcomes of the change, avoidance of placing one’s personal biases above the needs of the organization, and the firm but gentle use of one’s authority. Because of the complexities of the process of creating change, when resistance to change is detected, a manager is at risk of perceiving it as a threat to authority or to the well-being of the organization. This may be true in some cases, but in other cases workers will resist simply to expose something that the manager or the organization has missed about the proposed or pending change and its impact. In other words, resistance to change, depending upon its purpose and source, can have positive or destructive results. Therefore, managers must carefully analyze resistance without becoming defensive about the proposed change (that they may have helped to develop) and make use of it to strengthen the change process. Detecting Resistance to Change Managers can detect feelings of resistance to the change in both indirect and direct ways. The way in which workers communicate about the upcoming change can convey an underlying tone of discontent, ambivalence, resignation, or anger, or workers may mask their discontent in the presence of the manager. Sometimes resistance is blatant—frustration, bitterness, or anger can be obvious in body language, tone of voice, and in what is said. However, discontent can subtler, and managers need to be sensitive to smaller, less obvious changes in the attitudes of the staff toward their job duties, clients, other staff, and the manager. Transition generally coincides with at least some increased stress, but if a worker’s behavior or response is uncharacteristic or not in proportion to the change process or effects, there may very well be issues at play that have not been fully expressed or resolved. During indirect resistance, workers may still be moving toward implementing the change but in ways that make the change process less efficient and put the outcomes at risk. Resistance to change can also be manifested in direct actions taken by workers to reduce the amount and intensity of the change and to increase the time needed to meet the deadline for full implementation. In the vast majority of times of change, both acceptance of and resistance to the change will be present across the organization and within some departments. An individual worker might feel simultaneously committed and resistant to making the change (Appelbaum et al., 2015). 195 Active resistance, such as intentionally sabotaging the change process or rallying others to do so, requires a manager’s prompt attention and intervention. However, whether the resistance is active or passive, managers must be prepared to recognize the presence of resistance to change within an organization, judge the degree to which resistance will either positively or negatively affect the proposed changes, reassess the proposed change process, and take action to move the organization in the direction of growth and development. It is the responsibility of managers to make reasonable efforts to reduce negative resistance to change, which can manifest as underproduction while on the job, increased use of sick leave, active pursuit of new positions outside of the organization, and encouragement of peers to follow suit. Review Questions 1. What are the 3 basic characteristics of change that a worker will use to judge its acceptability and achievability? How will attention to these characteristics help occupational therapy managers to avoid negative resistance to change? 2. What are the 6 basic needs of workers? How do perceived changes in these needs contribute to negative resistance to change? 3. What are indications that workers are resisting a proposed change? PRACTICAL APPLICATIONS IN OCCUPATIONAL THERAPY Occupational therapy managers can prevent resistance to change by creating a work environment that supports change. Managers can also address and minimize negative resistance to change by making use of the evidence from organizational management research, including use of authentic leadership behaviors (Agote et al., 2016). The foundation for reducing negative resistance to change is to develop a trusting, collaborative, and supportive foundation within the department. Open and Transparent Communication Essential to developing change that minimizes negative resistance is the manager’s willingness to welcome affective reactions and to communicate honestly and transparently about the need for change as well as the potential benefits, risks, and challenges the change carries (Cropanzano et al., 2017). A systematic review of change resistance literature indicated that trust in management enhances commitment to the organization and reduces resistance to change (Oreg et al., 2011). Early involvement of workers who will be affected by the change in the process of identifying problems and opportunities, conducting research and inquiries about the change, and exploring strategies for creating the change will help to prepare them for what is to come, encourage investment in the process, and proactively mitigate against negative resistance. Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 196 SECTION III. Navigating Change and Uncertainty Demonstrate Pride and Confidence Managers should think of themselves as facilitators, rather than imposers, of change. By initially emphasizing a change’s positive outcomes and benefits, managers can set a foundation for garnering support. To approach a major change with a sense of dread invites failure, erodes confidence, and encourages avoidance of the process. In many cases, changes to systems and operations are welcomed and expected by workers, and resistance is due to investment in smoothly transitioning to the new way of performing work responsibilities. When managers feel negative resistive undertones, open discussions and expression of pride in the proposed change can be helpful. The challenge to such discussions will be to avoid the sense that an individual or group such as the direct manager or the organization administrators are the decision makers and that the workers are the ones required to carry out the change. However, if managers instead adopt a policy of silence and plan a change in isolation, the results are likely to be even more destructive. For workers, simply being required to implement changes without any previous voice in the process of creating the change can be seriously problematic. Workers, especially those who have professional education and training, are invested in using their knowledge and skills efficiently and effectively. They want to be consulted early enough in the change process to have their perspectives and insights considered, and they want to be given the chance to express their opinions before change is imposed. Acknowledging their expertise and demonstrating respect for their knowledge and skill is important. If staff feel that their ability to do their job well and properly treat clients has not been taken into consideration, they are likely to lack buy-in for the proposed changes. Although it is not always possible for employees to have a voice in all changes that they are asked to make, consulting with them whenever possible prior to implementing a change can go a long way to minimize resistance because it affords them the respect they deserve as contributors to the growth and betterment of the organization. Therefore, it is recommended that the manager engage workers throughout the change process, show confidence that creating a currently proposed change is both feasible and beneficial to the organization and its workers, and, once implemented, express and demonstrate pride in the positive changes that are being created in the work environment (Lindebaum & Jordan, 2012). positions of leadership in the change process serves to increase the number of staff who openly show support for the change and may offer opportunities for people who are feeling resistant to further explore the benefits of the change with a peer (Anderson & Anderson, 2010a; Houmanfar et al., 2017). Use Shorter Range Objectives to Build Toward the Ultimate Goal Just as occupational therapy practitioners break down activities into component parts to achieve long-term goals, Dasborough et al. (2015) have emphasized the value of focusing on changes that can be implemented in the present and near future while maintaining stability within the organization. Demonstrating how small changes can lead to a larger restructuring can ease tensions and maintain a sense of control, inclusion, and empowerment, thereby reducing the potential for resistance (Curtis & White, 2002). Seek Assistance From Superiors and Consultants Occupational therapy managers must foster the same types of bonds with their superiors that they wish to develop with their staff. Knowing when to seek assistance, express concerns, and discuss challenges and barriers to the growth and development of their departments are essential skills in reducing negative resistance to change. Modeling such actions further demonstrates to employees the importance of problem solving, insightfulness, and judgment as essential components to addressing resistance to change. With occupational therapy practitioners’ extensive experience with task analysis and goal setting, the process of examining potential and proposed changes and visualizing the means to help structure those changes in a step-by-step process requires the application of a skill set that occupational therapy practitioners and managers have learned and practiced. Applying this skill set in a management context may require consultation with superiors or with consultants from outside the organization. The former increases the likelihood that all levels of the organization are seeing the change similarly. The latter provides a perspective from people who are not enmeshed in the change process and can often offer an alternative perspective on reasons for resistance to the change. Case Example 20.1 illustrates handling resistance to change at a rehabilitation hospital. Support Prosocial Behavior Review Questions Occupational therapy managers can show support for behaviors that create a positive social structure within the organization and promote peer encouragement, confidence in goal achievement, ability to contribute to the betterment of the organization, and feelings of empowerment. Analysis of the social context within the organization will assist the manager to recognize workers who strive to create a supportive, change-oriented environment. Placing those individuals in 1. How can occupational therapy managers support prosocial behavior to reduce resistance to change? 2. What is the value of developing short-term objectives for change that build toward the ultimate goal of the organization? 3. Why is it useful for occupational therapy managers to model positive communication with superiors and consultants when experiencing resistance to change? Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 20. Handling Resistance During Change 197 CASE EXAMPLE 20.1. Creating a New Evaluation Process Identifying the problem Occupational therapy, physical therapy, and nursing managers at a rehabilitation hospital affiliated with a large university medical center began recognizing inconsistencies in the reporting of admission, progress, and discharge information among practitioners working on 3 rehabilitation units. One unit was designated for patients with spinal cord injuries, 1 for acquired brain injuries, and 1 for general rehabilitation. Senior members of the rehabilitation teams on each unit remained consistent, but the majority of occupational therapy practitioners and nurses rotated to a new unit every 3 months. The management team had reviewed medical records over a 3-month period and found that evaluation measures and procedures varied across the 3 units and had a variety of gaps and overlaps within and across disciplines. This information was consistent with what the occupational therapy manager had been hearing from some of the members of her team. Team members also described how the inconsistences required them to reorient themselves to a new system of evaluating patients and reporting results every 3 months. One senior occupational therapy practitioner shared with the occupational therapy manager that, while several practitioners were in favor of a change in evaluation procedures, others felt it was prudent to leave well enough alone and that 1 change would lead to others, making their jobs more stressful. Seeking solutions Having identified a basic problem, the occupational therapy manager, in collaboration with her peers in physical therapy and nursing, met with the director of rehabilitation to share results of the medical record review, propose revision of the evaluation system, and inform the director of both interest in and potential resistance to the change. The director tasked the 3 managers to create uniform evaluation procedures across all units, designate specific evaluation responsibilities to each discipline, and pilot test the procedures. Following the meeting with the director, the managers met to discuss goals of the project, concluding that the main issues were to find a measure that addresses a majority of the needs of rehabilitation patients, covers the scope of practice of occupational therapy, physical therapy, and nursing, has clear competency training procedures, and can be operational in 4 months as required by the director. The managers agreed that creating the uniform system of evaluation may best be carried out by permanently assigning all staff to 1 of the 3 units. To develop and implement the plan, the occupational therapy manager made the following list of things to do: ■ ■ ■ ■ Discuss with management peers (i.e., physical therapy, nursing) when and how to present and discuss results of the medical record review with staff. Within 1 week of the meeting with the director of rehabilitation, discuss findings of the medical record review at the upcoming occupational therapy staff meeting. Inform the staff of a new decision to change the evaluation procedures, with a goal to put the plan into operation in 4 months. Emphasize their early involvement in the process and express confidence that the change will be positive. Welcome expression of interests and concerns. Appoint a senior occupational therapy staff member to chair a committee of senior and junior staff to further describe evaluation problems as they see them and propose potential solutions. Gather information and analyze reactions to the proposed changes at the initial meeting and from the chair of the committee to determine the extent of the resistance to change. Exploring emotional responses to change, including resistance The occupational therapy manager concluded that the staff have both positive and negative reactions to the proposed change. Practitioners expressed the following concerns: ■ ■ ■ ■ ■ I’ve never been good at treating people with spinal cord injuries, and I don’t like working with that population. What if I get assigned to that unit? This happened at my last job, too. I was really efficient at evaluating patients the old way, but then they imposed this new system that I couldn’t get down. The hospital is just trying to come up with ways to save money by reducing the occupational therapy staff. I was one of the last people hired, so my job is in jeopardy. We have to become efficient in new assessment procedures, add new tasks to our evaluation process, and adjust to working on newly assigned units all at once. That seems like a lot of changes to make in a short amount of time. The hospital has no right to decide how I evaluate patients. My professional judgment is being undermined. We need to go to human resources about this. Reshaping the plan to reduce resistance to change Much of the occupational therapy manager’s process had addressed potential resistance to change from the onset. She had carefully met with her director and management peers to define the problem and seek ideas for how to address it. She brought her staff together to inform and involve them early in the process. She identified supportive staff who typically encouraged prosocial behavior to be leaders of a committee that sought input and feedback, also providing an alternative mechanism for staff to express their concerns. The occupational therapy manager anticipated the inevitability of emotional responses to change and acted proactively, obtaining information on the level of resistance to change to revise plans that would smooth the transition to the new evaluation process (Appelbaum et al., 2015). In doing so, she avoided becoming defensive about the resistance and negatively labeling any individual staff member (Anderson & Anderson, 2010a). Instead, she used the information to create a more reasonable and acceptable change process. (Continued) Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 198 SECTION III. Navigating Change and Uncertainty CASE EXAMPLE 20.1. Creating a New Evaluation Process (Cont.) As a result of the information she obtained, the occupational therapy manager met with the management team, which then proposed to the director to move the time to fully operationalize the change back by 2 months and make the original 4-month deadline implementation of a 2-month pilot phase. Prior to full implementation, the occupational therapy manager set shorter range objectives to identify appropriate assessment tools, complete training and competency requirements, and practice use of the evaluation procedures for a range of clients on different units. The management team also asked the director to send a memo to staff informing them that the change in the evaluation process would not reduce the need for current positions and might even increase opportunities. With assistance from the other managers, the occupational therapy manager invited 3 teams of occupational therapy practitioners and nurses from other rehabilitation centers to present the evaluation methods they were using. She then brought her staff together to discuss advantages and challenges to each evaluation procedure and to provide feedback on how each measure addressed the occupational therapy scope of practice. Once the final assessment tool was identified, the staff was invited to propose revisions to the evaluation process that addressed the uniqueness of their setting. In doing so, the occupational therapy manager eased some of the tension about professional autonomy in the evaluation process and was able to acknowledge the advanced skill and competence of the staff, all resulting in less resistance to the change. Finally, while the plan to assign all staff to working on only 1 unit was still considered an efficient change strategy, the occupational therapy manager suggested that this change could be implemented separately from and at a different pace than the change in the evaluation procedures. She proposed to delay it by 18 months and to establish a process whereby occupational therapy practitioners could demonstrate competencies in skills needed for specific units for consideration of permanent placement, while also instituting new hiring practices that recruited practitioners for roles on specific units. Review Questions 1. 2. 3. What cues did the occupational therapy manager receive that indicated resistance to change? How did the occupational therapy manager address resistance? What assistance did the occupational therapy manager rely on to reduce resistance to change? SUMMARY ACOTE STANDARDS Emotional responses, including resistance, are inevitable components of change (Dasborough et al., 2015). An occupational therapy team will resist change for many reasons, some personal, others based on investment in the organization and the people it serves. Not all resistance to change is negative, and resistance should not be perceived as deviant behavior (Mathews & Linski, 2016). Under the right circumstances when managers create the right opportunities for resistance to be appropriately expressed and framed in a way that solutions can result from the identification of issues that need to be considered, resistance to change can serve a valuable purpose. It can be extremely helpful, contributing to the process of making the right changes at the right time rather than adding to problems. However, negative resistance can reduce the efficiency and effectiveness of the proposed change in ways that require occupational therapy managers to remain alert and proactive to its potential and seek solutions to it when it is present. Occupational therapy practitioners will judge the amount and quality of a proposed change in relation to the time required to make it, and resistance to change will often occur when workers feel the amount, quality, and time components of the change are unachievable. Additionally, recognizing factors that may predispose practitioners to resistance can assist managers to channel or reduce it. Occupational therapy managers can reduce resistance to change by carefully examining achievable amount, quality, and time factors; recognizing when resistance is present; anticipating and planning for resistance to change; and responding to resistance through use of prosocial behavior, open communication, and demonstrations of pride and confidence in the team. ❖ This chapter addresses the following ACOTE Standards: ■ B.5.1. Factors, Policy Issues, and Social Systems ■ B.5.3. Business Aspects of Practice ■ B.5.7. Quality Management and Improvement. REFERENCES Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org /10.5014/ajot.2018.72S217 Agote, L., Aramburu, N., & Lines, R. (2016). Authentic leadership perception, trust in the leader, and followers’ emotions in organizational change processes. Journal of Applied Behavioral Sciences, 52, 35–63. https://doi.org/10.1177/0021886315617531 Anderson, L. A., & Anderson, D. (2010a). Getting smart about employee resistance to change— Part one. Retrieved from http://www .beingfirst.com/resource-center/pdf/SR_GettingSmartAbout Employee%20ResistanceToChg_PtOne_v3_101006.pdf Anderson, L.A., & Anderson, D. (2010b). Getting smart about employee resistance to change—Part two. Retrieved from http://www .beingfirst.com/resource-center/pdf/SR_GettingSmartAbout Employee%20ResistanceToChg_PtTwo_v3_101006.pdf Appelbaum, S. H., Degbe, M. C., MacDonald, O., & Nguyen-Quang, T.-S. (2015). Organizational outcomes of leadership style and resistance to change (Part 1). Industrial and Commercial Training, 47, 73–80. https://doi.org/10.1108/ICT-07-2013-0044 Cropanzano, R., Dasborough, M. T., & Weiss, H. M. (2017). Affective events and the development of leader–member exchange. Academy of Management Review, 42, 233–258. https://doi.org /10.5465/amr.2014.0384 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] CHAPTER 20. Handling Resistance During Change Curtis, E., & White, P. (2002). Resistance to change: Causes and solutions. Nursing Management, 8(10), 15–20. Dasborough, M., Lamb, P., & Suseno, Y. (2015). Understanding emotions in higher education change management. Journal of Organizational Change Management, 28, 579–590. https://doi .org/10.1108/JOCM-11-2013-0235 DeCelles, K. A., Tesluk, P. E., & Taxman, F. S. (2013). A field investigation of multilevel cynicism toward change. Organization Science, 24(1), 154–171. https://doi.org/10.1287/orsc.1110.0735 Elstak, M. N., Bhatt, M., Van Riel, C. B. M., Pratt, M. G., & Berens, G. A. J. M. (2015). Organizational identification during a merger: The role of self-enhancement and uncertainty reduction motives during a major organizational change. Journal of Management Studies, 52, 32–62. https://doi.org/10.1111/joms.12105 Frese, M., Garst, H., & Fay, D. (2007). Making things happen: Reciprocal relationships between work characteristics and personal initiative in a four-wave longitudinal structural equation model. Journal of Applied Psychology, 92, 1084–1102. https:// 10.1037/0021-9010.92.4.1084 Fugate, M., Prussia, G. E., & Kinicki, A. J. (2012). Managing employee withdrawal during organizational change: The role of threat appraisal. Journal of Management, 38, 890–914. https:// doi.org/10.1177/0149206309352881 199 Houmanfar, R. A., Alavosius, M. P., Morford, Z. H., Herbst, S. A., & Reimer, D. (2017). Functions of organizational leaders in cultural change: Financial and social well-being. Journal of Organizational Behavior Management, 35, 4–27. https://doi.org/10.1007 /s40614-016-0064-7 Jacobs, G., & Keegan, A. (2016, September 2). Ethical considerations and change recipients’ reactions: “It’s not all about me.” Journal of Business Ethics. https://doi.org/10.1007/s10551-016-3311-7 Lind, E. A., & van den Bos, K. (2002). When fairness works: Toward a general theory of uncertainty management. Research in Organizational Behavior, 24, 181–223. https://doi.org/10.1016 /S0191-3085(02)24006-X Lindebaum, D., & Jordan, P. J. (2012). Positive emotions, negative emotions, or utility of discrete emotions? Journal of Organizational Behavior, 33, 1027–2030. https://doi.org/10.1002/job.1819 Mathews, B., & Linski, C. M. (2016). Shifting the paradigm: Reevaluating resistance to organizational change. Journal of Organizational Change Management, 29, 963–972. https://doi .org/10.1108/JOCM-03-2016-0058 Oreg, S., Vakola, M., & Armenakis, A. (2011). Change recipients’ reactions to organizational change: A 60-year review of quantitative studies. Journal of Applied Behavioral Science, 47, 461–524. https://doi.org/10.1177/0021886310396550 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] Communicating During Change or Uncertainty CHAPTER Sheila Moyle, OTD, OTR/L, and Bridget Trivinia, OTD, MS, OTR/L 21 LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Describe cultural, socioeconomic, technological, political, legislative, and competitive factors that affect change in ■ ■ ■ ■ occupational therapy practice; Explain the roles of occupational therapy managers and stakeholders during the change process; Understand and analyze models for managing communication during times of change; Identify steps of the change management process; and Analyze effective communication strategies for use during times of change. KEY TERMS AND CONCEPTS • • • • • • • Autocratic leadership Change Change agent Change implementers Change process framework Change recipients Change strategists • Cognitive appraisal theory of • • • • • emotions Communication Democratic leadership Hierarchical distance Integrated conceptual model Laissez-faire leadership OVERVIEW C hange (i.e., to alter or make different) is constant; people of all ages experience differences between anticipated and actual norms and outcomes of conditions. Change occurs across the lifespan as life unfolds, and it can be unexpected or planned. Change demands flexibility, skill, and support for all stakeholders to react effectively. Change is sustained through implementation and human communication (i.e., the act of conveying information from 1 person to another; DeIuliis & Flinko, 2016). When change occurs in the workplace, a manager’s ability to communicate will affect outcomes during times of uncertainty. Many factors contribute to the success of change within an organization. A manager’s ability to gather, communicate, and share information is recognized as significantly contributing to the success of organizational change (Baur et al., 2017; Endrejat et al., 2017; Matos Marques Simoes, & Esposito, 2014). This chapter examines how information is gathered and shared • • • • • • • Middle managers Participatory change model Programmatic change model Resistance to change Stakeholders Stakeholder mapping Top management team during uncertain times and explores the management skills necessary for navigating change. ESSENTIAL CONSIDERATIONS Communication has been recognized as a significant element in the success of organizational change. It has been studied by numerous disciplines, including nursing, psychology, business, and personnel management (Baur et al., 2017; Endrejat et al., 2017; Matos Marques Simoes & Esposito, 2014). When we think of communication, we often think of the act of exchanging or imparting information from person to person. However, communication can also be considered a social process in which meaning is constructed on the basis of the culture and context rather than simply a transmission of meaning (DeIuliis & Flinko, 2016; Nanjundeswaraswamy & Swamy, 2014). In the workplace, the organizational culture affects the communication process. Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com. https://doi.org/10.7139/2019.978-1-56900-592-7.021 Purchased from AOTA for the exclusive use of Alyssa Myers ([email protected] 000004564714) © 2020 AOTA. Please report unauthorized use to [email protected] 201 Communicating During Change or Uncertainty CHAPTER Sheila Moyle, OTD, OTR/L, and Bridget Trivinia, OTD, MS, OTR/L 21 LEARNING OBJECTIVES After completing this chapter, readers should be able to ■ Describe cultural, socioeconomic, technological, political, legislative, and competitive factors that affect change in ■ ■ ■ ■ occupational therapy practice; Explain the roles of occupational therapy managers and stakeholders during the change process; Understand and analyze models for managing communication during times of change; Identify steps of the change management process; and Analyze effective communication strategies for use during times of change. KEY TERMS AND CONCEPTS • • • • • • • Autocratic leadership Change Change agent Change implementers Change process framework Change recipients Change strategists • Cognitive appraisal theory of • • • • • emotions Communication Democratic leadership Hierarchical distance Integrated conceptual model Laissez-faire leadership OVERVIEW C hange (i.e., to alter or make different) is constant; people of all ages experience differences between anticipated and actual norms and outcomes of conditions. Change occurs across the lifespan as life unfolds, and it can be unexpected or planned. Change demands flexibility, skill, and support for all stakeholders to react effectively. Change is sustained through implementation and human communication (i.e., the act of conveying information from 1 person to another; DeIuliis & Flinko, 2016). When change occurs in the workplace, a manager’s ability to communicate will affect outcomes during times of uncertainty. Many factors contribute to the success of change within an organization. A manager’s ability to gather, communicate, and share information is recognized as significantly contributing to the success of organizational change (Baur et al., 2017; Endrejat et al., 2017; Matos Marques Simoes, & Espo
