Working Remotely: What Physical Distancing Can Teach Us About Working Together
May 2020 Issue
When this article was written, much of the US population was under stay-at-home orders designed to slow the spread of COVID-19.1 Because O&P is considered among the essential services that are exempt from these orders, many O&P practices were adapting business practices and work schedules to ensure added protection to their patients and employees while continuing to provide services. Most of these changes involve minimizing the chances of transmission and exposure while performing the clinical and administrative tasks that require physical presence within a facility. Employees in professions whose work can be completed by communicating and collaborating electronically, rather than relying on face-to-face interactions, have made significant changes to how work is performed. However, O&P is a hands-on profession. The activities that define our profession require physical contact with patients and being close to family members, caretakers, and other healthcare professionals. While it will never be possible to perform the core tasks of our profession remotely, considering the ways in which workplace interactions in other professions are affected by physical proximity or distancing may help us find ways to make O&P business and clinical operations more effective. This article includes ideas about different ways to work together by adopting alternative strategies that have been successful in other professions.
What Type of Workforce Are We?
Historically, O&P has been defined by the devices we provide. Our profession was recognized as an allied health profession in 1992, but a reimbursement structure that pays for devices, not services, reinforces the image of O&P clinicians as manufacturers and product vendors.2 A few months ago, a certified clinician was speaking with Northwestern University Prosthetics-Orthotics Center (NUPOC) students about preparing for residency and clinical practice. He used the term project manager to describe how he spends his time in a busy practice that includes a technical staff and on-site fabrication capabilities. Like many practitioners, he uses his knowledge and expertise for evaluation, shape capture, and fittings and spends a significant amount of time managing communication with referral sources, payers, and technical staff. While many practitioners perform fabrication, some employers recognize that practitioners can use that time to make more significant contributions in other areas of clinical practice. It would be strange to consider someone a prosthetist/orthotist if they never actually provided prostheses and orthoses, but describing something as essential to that role does not mean that it is sufficient to fulfill all of the responsibilities that come with it. Regardless of how clinical and technical work is divided among available staff, clinical care involves distinct sets of skills. Effective care requires many skills other than those involving direct, physical contact with patients, and many of those other skills may actually be more important to successful practice.
More than fifty years ago management guru Peter Drucker emphasized the importance of knowledge work and the knowledge worker. A knowledge worker is someone "whose main capital is knowledge."3 Knowledge work is associated with creative work, handling and distributing information, and an increased level of autonomy. Manual or unskilled labor often involves repetitive tasks that must be performed at a specific location. Knowledge work tends to be less dependent on location, with more emphasis on work product than how or where it is produced. Since most jobs require both knowledge and skills, it can be difficult to determine which jobs fall into this category, and the term may be less useful than it was decades ago.4 While the increase in remote work has been dramatic in the past decade, the vast majority of workers in the United States still complete their work at the same physical location as their coworkers. According to a February article, "Between 2005 to 2017, there was a 159% increase in remote work. In 2015, 3.9 million US workers were working remotely. Today that number is at 4.7 million, or 3.4% of the population."5 It is likely that a lower percentage of the O&P workforce was working remotely prior to the recent stay-at-home orders. In our profession it may be more helpful to distinguish which tasks can be performed remotely from those that must be performed in person.
A 2014 article inThe Academy Today discussed the application of telemedicine (a form of remote work within healthcare) to four domains of the American Board for Certification in Orthotics, Prosthetics & Pedorthics' (ABC's) Practice Analysis. The Practice Analysis surveys practitioners to determine, among other things, how much time is spent performing tasks in a variety of domains of practice.6 "Since almost all aspects of implementation and key aspects of follow-up involve physically performing procedures on a patient or a device, these domains do not represent significant opportunity for the application of telemedicine. To the extent that follow-up involves the adjustment and refitting of a device, it also falls outside the scope of telemedicine…. This leaves the domain of assessment as the area with the most telemedicine potential for O&P."6 After describing an analysis of tasks within the assessment and follow-up domain, the review concluded that "telemedicine could significantly improve the efficiency of care during tasks that typically consume one-third of the average practitioner's time."6 If 30 percent of our time as clinicians does not require direct contact with patients, it is worth considering how business and clinical practices can be modified to make the performance of these tasks more efficient and effective while giving clinicians more autonomy.
The Open Office
One strategy that employers have promoted to improve work environments is an open office design of the physical space. Rather than give each employee a private work area, workstations are arranged in large spaces with minimal physical divisions. It has been known for some time that this type of architecture does not improve efficiency or productivity, and that it comes with significant disadvantages. (The one thing it does well is reduce construction costs.) Two researchers from Harvard University used data obtained from wearable devices and electronic communication servers to compare the interaction patterns between employees in two large companies before and after they transitioned from a traditional, wall-bounded architecture to an open office floor plan. Contrary to the assumption that the open office arrangement would increase face-to-face interaction and collaboration, these researchers found that face-to-face interaction declined by about 70 percent. This drop in physical interaction in the open-office environment was partially replaced by electronic communication (emails and instant messaging). The researchers found that in an environment that forced physical interaction by limiting physical barriers, workers intentionally created private space (e.g., by wearing headphones) in which to complete their work. The open office arrangement had an effect directly opposite of that which was promoted as the reason for its adoption.7
While O&P clinical tasks are usually performed in private or semi-private spaces, much of the administrative work clinicians perform is completed in open areas of a facility. Many companies in other professions have addressed the challenges of the open office arrangement by creating small, private spaces that can be scheduled for individual work or small group collaboration. Creating this type of space within an O&P facility could be done at minimal cost and may improve the effectiveness of knowledge workers by reducing distractions and interruptions. When IT systems permit, many clinicians already complete clinical and administrative tasks from home and after hours. Employers could build trust and encourage autonomy by supporting completion of these tasks remotely during normal business hours. The added flexibility may improve productivity and job satisfaction, as it has in other professions.6
A Distributed Workforce
In a March 24 interview on the "Making Sense" podcast, Sam Harris spoke with Matt Mullenweg about the evolution of distributed work. Mullenweg is "a founding developer of WordPress, the Open Source software used by 36% of the web."8 For 15 years he has led a company with a distributed work force, and currently has over 1,000 employees working in 75 countries. He prefers to use the term distributed since remote implies that there is a central location for the business (which his company does not rely on) and there are negative associations with the idea that some employees are not as closely connected to that location. Since O&P business do rely on a physical location, remote may be the more relevant term for our profession. Still, Mullenweg's perspective can provide insights into how O&P clinicians can be effective when working remotely.
Autonomy involves the ability to determine how a job gets done, and Mullenweg describes different levels of distributed work arrangements based on how much autonomy the worker is given. Most companies function at Level 1, where nothing deliberate is done to allow remote work. In emergencies employees can complete some duties outside of the office. Taking a phone call and completing other administrative tasks is possible while home sick, on vacation, or when attending a meeting, but at this level most work gets put off until the worker returns to the office. At Level 1, the company system is not designed for remote work, so workers will not be as effective as they are while in the office. At Level 2, companies attempt to "recreate what you did in the office, but just do it online."8 This is most likely what many companies have done recently in response to stay-at-home orders. In a workplace designed for onsite workers,
a remote worker is often more disconnected from other employees, which can challenge efficiency and productivity. At Level 3, companies and workers begin to take advantage of the new way of working and expand their use of improved equipment and strategies such as video calling, shared electronic documents, and many other tools. Level 4 involves asynchronous collaboration and workers completing work on their own schedules. It is likely that this level is unnecessary for all but the few O&P companies with nationwide offices.
A fully distributed workforce is unlikely in O&P, although practices that exclusively use a mobile practice model may come close to this design. It may be helpful for practices to evaluate ways to complete knowledge work that allow more autonomy and flexibility while maintaining high levels of efficiency and productivity. Offering remote work options may also allow companies to retain valuable and trusted employees who may need to physically relocate due to personal and family reasons.
Improving Written Communication
According to Mullenweg, a distributed work arrangement requires improved writing quality, clarity, and skill. Particularly in a cultural environment of heightened sensitivity, we should be mindful that people may interpret what we write less positively than it was intended. Mullenweg uses the acronym API, which stands for "assume positive intent," to describe the proper attitude when reading messages from coworkers. He compares this to Postel's Law, a programming concept that serves as a metaphor for being conservative in what is communicated and liberal in what is accepted.9 He advises giving added attention to how we communicate with coworkers using digital platforms (e.g., email, text, and Slack) and including extra "fluffy language" and even emojis. He also recommends including more clarifying language in some forms of communication. Instead of simply responding "yes" to a question that is texted, repeating back the specifics of what is being agreed to or approved can ensure that the proper message is communicated. Switching mediums by placing a phone call when written communication gets tense can defuse difficult interpersonal situations.
The biggest challenges facing our profession are not clinical or technical. Advancements in device design and control strategies have dramatically expanded the options we can provide patients, and most employers and clinicians are committed to constantly improving those clinical skills to improve our patients' lives. The biggest barriers we have to surmount are related to the knowledge side of our profession. Making changes to our work arrangements to allow knowledge workers greater flexibility and autonomy may be one way to support them in completing their work at the highest level. O&P will remain a person-focused, hands-on profession, highly dependent on face-to-face encounters with patients. Implementing some of Mullenweg's Level 3 strategies may improve our business and clinical operations and give practi-tioners the autonomy to perform at their highest level.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has over 25 years of experience in patient care and education. He can be contacted at firstname.lastname@example.org.
6. Brinkmann, J. T. 2014. Telemedicine and the ABC Practice Analysis. The Academy Today 10(2):A5-7 http://digital.publicationprinters.com/publication/?i=559109
7. Bernstein E. S., Turban S. 2018. The impact of the ‘open' workspace on human collaboration. Philosophical Transactions of the Royal Society B 373:20170239. http://dx.doi.org/10.1098/rstb.2017.0239