The Change in ‘Productivity’ Why does productivity exist? How did we get here? Can it be managed well? From My Perspective
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From My Perspective  |   September 01, 2018
The Change in ‘Productivity’
Author Notes
  • Ed Garrett, MS, CCC-SLP, is district director of rehab for Sava Senior Care, a provider of skilled nursing, memory care and rehabilitative services. egarrett02@yahoo.com
    Ed Garrett, MS, CCC-SLP, is district director of rehab for Sava Senior Care, a provider of skilled nursing, memory care and rehabilitative services. egarrett02@yahoo.com×
Article Information
Special Populations / Older Adults & Aging / Healthcare Settings / Practice Management / Professional Issues & Training / From My Perspective
From My Perspective   |   September 01, 2018
The Change in ‘Productivity’
The ASHA Leader, September 2018, Vol. 23, 6-7. doi:10.1044/leader.FMP.23092018.6
The ASHA Leader, September 2018, Vol. 23, 6-7. doi:10.1044/leader.FMP.23092018.6
Productivity may be the most controversial term in skilled nursing facility-based health care. It is certainly one of the most unpopular terms. To managers it can be an important measure of labor use, yet to more than a few clinicians, it is almost synonymous with inappropriate pressure (see “Under Pressure”).
It begs the questions, why do we have productivity measures at all? How has it been used and misused? And where do we go from here?
Simply put, productivity is the percentage of time in a facility that a clinician (or team) is providing billable care to residents. If managed well, the cost of therapy services remains reasonable while meeting the rehab needs of the residents. I realize your experience may not match this description, but stay with me for now ….
A shift in models
In the early days of rehab in skilled nursing facilities (SNFs), payment was handled under cost-based reimbursement. It was a highly complex system in terms of accounting, but what was important in rehab was to deliver enough care to more than cover the cost of providing that care. To ensure that a company was meeting that standard, some used a measure called units per clinician (as therapy was often billed in 15-minute blocks rather than by Healthcare Common Procedure Coding System [HCPCS] codes). Others used the percentage of the clinician’s day spent in providing care, now known as productivity.
As we progressed through the introduction of a prospective payment system, that percentage measure became the standard for the SNF setting. While not popular, it still worked better for rehab than the per-patient day (PPD) ratio used in other SNF departments.
PPD is based on the facility’s patient census: When the total census of the facility rises, there are more hours of labor available, and when the census drops, fewer hours of labor are needed. That works for most departments—such as nursing and food service—which serve the entire population of a facility. It doesn’t work for rehab, because our caseload can vary independently of the census. That leaves productivity as the only viable method managers have to match labor cost with rehab needs on a day-to-day basis.

A good manager will look first to the programming needs of the residents and the facility. A good manager will ensure that the staff have the knowledge and skills to meet those needs, and constantly look to improve overall rehab programming. Productivity will still matter, but it is managed through good clinical programs rather than by manipulating a number.

‘Off the clock’ problems
The problem comes when you look at productivity standards and how they are managed.
The first thing to know about productivity standards is that there is no standard approach to productivity. Every company has a different formula for calculating productivity, with some companies counting as “productive time” things that other companies do not. To understand and compare the standards of different companies, you really need to know their formula, not just the “standard” number. A lower “standard” number at one company may be harder to achieve than a higher “standard” number somewhere else.
And it’s more than the company “standard.” It’s how you manage productivity.
Is it possible to over-manage productivity? Based on what we have seen and heard, absolutely! If productivity is the overriding concern, and if the number matters more than anything else, bad things can happen. That kind of management ignores clinical needs and serves only one purpose … making a number look “good.” If a manager does not have a good understanding of clinical program development across the disciplines, the result can be pressure to just “do more” without regard to clinical needs. The pressure from this approach may result in unnecessary minutes of care, or it can result in clinicians who work “off the clock” to make their productivity appear “good.”
There is absolutely nothing good in this approach.
A good manager will look first to the programming needs of the residents and the facility. A good manager will ensure that the staff have the knowledge and skills to meet those needs, and constantly look to improve overall rehab programming. Productivity will still matter, but it is managed through good clinical programs rather than by manipulating a number. That manager won’t overreact to one “bad” day, and won’t put inappropriate pressure on the staff. There are good managers out there, and we need more of them.
The SNF setting poses time-management challenges. One has to change schedules on the fly, and document quickly—but completely—with skilled interventions noted. Still, no matter the pressure felt, a clinician cannot provide inappropriate care. And working “off the clock” is not the answer. It’s not fair to the clinician and can create additional issues under labor law.
In the end, a SNF rehab manager has two major obligations. The first and foremost is to ensure excellent patient care under the highest ethical standards. The manager also has a fiduciary obligation to the company to manage labor costs wisely while providing that care. Those two obligations do not have to conflict. There is a better way, and many providers practice that better way today. We all should.
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September 2018
Volume 23, Issue 9