The Philosophy of Outcome

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By Kelly Clark, CO
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I listened and observed for 12 years. In the beginning, I was more concerned about honing my craft as an educator and speaker, but as the years went by, I listened and observed with increasing focus. My work took me to nearly all of the lower 48 states where I met with clinicians who make our profession what it is today, and those interactions helped to shape the philosophy of outcome I address in this essay.

If there is one theme I would like you, as O&P clinicians, to understand, it is that you are not alone. Challenges abound everywhere throughout the United States. Some clinicians and business owners are meeting the challenges effectively, while others seem to be overwhelmed and are fighting a tough battle to maintain their businesses and their morale. I hope that the ideas discussed in this essay will provide some guiding principles that can help you meet the challenges you face. While the philosophy of outcome is always pertinent, it is increasingly relevant because of the direction in which the healthcare environment is moving. With the advent of Accountable Care Organizations (ACOs), the landscape has changed in terms of how we are paid or will be paid for the services we provide. The push is to move from a fee-for-service approach to a bundled approach for payment. Part of the metrics for payment to an ACO is performance. Performance is viewed as the best level of outcome provided in the most efficient manner. So the more proficient and efficient you are in your profession, the better equipped you will be to adapt to this environment.

All of us, whether we are cognizant of it or not, operate from a base philosophy. That philosophy guides our day-to-day decisions and occupies our vision for today, for tomorrow, and throughout our careers and lives. When I speak about the philosophy of outcome, I specifically mean the outcomes we endeavor to give our patients that impact their daily lives. Outcome can mean different things to different people, but in this context, I define it as the way in which the implemented orthotic or prosthetic intervention impacts the patient's life for the long term. As an example, one patient with whom I worked was only able to be up and functioning for about an hour per day and then was spent because of the energy expenditure in that hour. All work to ambulate relied on the upper-body strength required to use assistive devices, namely crutches. After the intervention, the patient was able to wean from all assistive devices in four months and began exhibiting 12 to 14 hours of function per day. This outcome has had a substantial impact, not just in the treatment room, but in all of that patient's activities of daily living (ADLs). I submit that outcome impacts the patient's life and ADLs. The better the outcome, the greater the degree of impact.

As I began the process of articulating this philosophy, I thought that understanding why people got into the profession would give me some insight into what basic characteristics an individual would possess to choose this profession. However, when I conducted an informal survey on LinkedIn, what I found with comments like, "The profession found me," or "It was fate," was that many of the respondents became part of this industry through serendipity. From that, I have to trust that underlying any reason for choosing this profession is the desire to make an impact in the lives of those who need our expertise.

What follows are some attributes of a philosophy of outcome that create the most profound impact in a patient's life. Like any philosophy, the details of implementation aren't spelled out here. The attributes are intended to be guiding principles as we seek to affect patients' lives in a positive way. Perhaps these would be best viewed as pillars in a mission statement.

Take Ownership of the Outcome

There is a saying, "As long as someone or something else is responsible for where you are, you will always be where you're at." Numerous times in my travels, I would inquire how a clinician had arrived at the decision to provide a particular level of outcome to a patient-one that would have less impact in the patient's life than what I would have expected. One response that comes to mind, and one that many of you can relate to, was that because of the Recovery Audit Contractor (RAC) audits, every patient would be treated as a K2-level patient even if he or she functioned at a higher K-level. This is detrimental for numerous reasons. First, these actions indicate that you weren't providing the appropriate modality to meet the patient's needs, and also, the billing was incorrect as a result. Finally, in assuming that every patient should be treated as if he or she demonstrates a K2 functional level, there seems to be little regard for thoroughly assessing the patient's needs and implementing an appropriate modality.

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Another reason frequently given as the driving force for choosing a particular O&P solution was the practitioner's comfort level and familiarity with a modality.

Working for a manufacturer kept me abreast of all the available state-of-the-art modalities. I helped conduct hundreds of clinics that focused on making the most impact in patients' lives and in their ADLs. This involved solutions from every manufacturer. I liked to follow up with the practitioners about successful cases to see how patients were doing, which was personally rewarding for me. Successful interventions could be measured by the number of times the practitioner was able to repeat the outcome. If we didn't see the subsequent occurrences with additional patients, then we would follow up after a time. What we often found was that the practitioner had gravitated back to what he or she was most familiar with. Getting familiar and comfortable with new modalities, even though successful, seemed to be viewed as too much work.

Part of taking ownership of the outcome is keeping up on the modalities that are available and what they can mean for your patients. There are numerous resources that can help you make that a reality. Through education and inquiry, you can be equipped to provide the solution that will have the greatest impact on a patient's life.

Be the Expert

Another theme that seemed to rise to the top was the lack of communication between the O&P clinician and the referral source. I looked at some of the education calendars for orthopedists and observed that there is little time spent on O&P. I did see a day devoted to clubfoot casting, but little in the way of O&P intervention. The most time was spent on anatomy, pathologies, and surgical measures to correct pathologies. Because of this, referral sources are often influenced by the latest sales representative who walks through their doors. I'm not suggesting that physicians can't make decisions about O&P treatments. However, when that decision is contrary to what you believe to be best for the patient, you need to bring your expertise to bear and have a conversation with the referral source to advocate for the patient. Ultimately, you are responsible for the O&P service delivered to the patient. So be a squeaky wheel, if need be, to guide the treatment. If you don't do this, you have been relegated to being an order filler.

Many times I heard, "That's what the doctor ordered," or "This doctor doesn't take suggestions for treatment," or "It is impossible to get through to the doctor to have that discussion." Look at this through the eyes of the patient. If you were the patient, would you want the practitioner to fit you with something that did not fully meet your needs, or would you want him or her to go to every length to secure the best option for you? When you think about it, what better marketing tool is there than to have a reputation for achieving the best outcomes for your patients, even under difficult circumstances?

Bury Your Ego

An ego, by definition, is self-serving and should not be confused with confidence. Ego is self-perception while confidence is an aggregate of experiences that make you the expert. Ego needs to tell people you are the expert. Confidence shows through deliberate actions and reputation that you are the expert. Ego thinks very few others can get it right. Confidence is a perpetual state of learning, many times through others. Ego loves the limelight and chases it. Confidence attracts the limelight then shines when in it.

When it comes to competition, there were a few phrases I encountered with moderate frequency. It usually went something like this: "My best marketing is my competition," or "I fix a lot of what they have done." Part of the philosophy of outcome compels us to be the best we can be. Every day should center on how to improve our skillset to best serve our patients and our profession. In other words, "How can we make each other better?"

One of the weaknesses I see in our profession is our fragmented persona when we need more unity and camaraderie. If your competition is providing a service that is harmful to the patient, ethically you should call it out. However, you need to know the background before making a judgment call. When in clinic, I learned to temper feelings of superiority when a patient would show up and say, "I have been to everybody in town, and nobody has been able to help me." I suspected it was likely going to be a difficult case that wasn't necessarily going to go smoothly. Even in light of that, I would do my best.

Another scenario exists in which it first appears that a clinician at a competing practice has not provided a patient with the appropriate service or device. For example, I observed a situation in which a practitioner spoke of a patient who had come in with a knee orthosis that "fit horribly and was doing little to correct the deformity." That practitioner then began to draw some harsh conclusions about the other practitioner who had provided this care. The patient's new practitioner assessed the deformity and cast the patient, a longtime knee orthosis wearer, in a corrected posture. The orthosis was fabricated and fit to the patient. During the initial fitting, the orthosis "needed some adjustments" so the orthosis would fit and the patient would be compliant with the prescribed wear schedule. Over the next few months and after several adjustments, the new orthosis looked and fit just like the one with which the patient had initially walked in the door.

This example illustrates why you should give others the benefit of the doubt. Treat your competition as colleagues, not enemies. Use each other to make everyone better. If there is an impasse when working together, then focus on being the best you can be. In the midst of that, know that you have put your best foot forward-all to provide the best care for the patient.

In review, the three pillars for the philosophy of outcome are to take ownership, be the expert, and bury your ego. If you use these as guiding principles, regardless of what led you to the profession, you can experience the intrinsic reward of knowing you have done your best for the patient who has entrusted his or her care to you.

Kelly Clark, CO, has been involved in patient care for more than 20 years. He is the president of Kelly Clark Consulting, Minneapolis, which offers clinical care, clinical education, process strategy, and speaking. He can be reached at www.kellyclarkconsulting.com.