Inertia by definition is “a property of matter by which it continues in its existing state of rest or uniform motion in a straight line, unless that state is changed by an external force.”
About three weeks ago Ellen and I began a new contract in the Pacific Northwest working in home health for a large clunky bureaucratic hospital system. And like most large clunky bureaucratic hospital systems they have a large clunky bureaucratic documentation system.
Bureaucratic: overly concerned with procedure at the expense of efficiency or common sense.
From what we can tell, they seem tailor made for one another. The only weakness in this comparison is that while the hospital system thrives and continues a steamroll like expansion, providing excellent care to the residents it serves, the documentation system ever teeters on the brink of crashing (twice in three weeks for me), wobbling on its foundation of process and structure, and endless required boxes to click.
Now, I understand why the system was built the way it is. Required click boxes create a nice report that has all of the CMS and JCAHO mandatory bits and pieces. I’s dotted and T’s crossed. By removing the possibility of clinician error, the system ensures compliance with every note painstakingly finalized.
Here’s the rub. By forcing clinicians to click all of the right boxes, it eliminates the possibility of a therapist “thinking outside of the box.” (Sorry) And if you are reading this, I would assume you are somewhat familiar with the influence that Dustin Jones and others have stressed to the home health community to STOP THINKING INSIDE THE BOX! Personally I try to fight this as well, even my most popular article runs in the same vein.
Just the other day I found myself in a clients home thinking, “I know this guy needs to do a dot agility drill, but there is nowhere to document that” and “there isn’t a box for that so maybe I should do something else with him instead.” You see, my problem is that I have been a therapist long enough to know the expected treatment, and what has unfortunately become “industry standard” amongst much of home health community. MED – “minimum expected documentation” (as opposed to “minimum effective dose”) can insidiously become the driver behind patient care as we all are inundated with additional responsibilities and declining reimbursements. Sometimes it is simpler to swim with the current rather than against. The status quo is so easy!
Frustrated and overwhelmed by arduous and redundant computer systems, while valid feelings, are still never excuse enough to alter patient care. As obvious as this sounds, prior to this experience, I had never actually found myself confronted with this sort of dilemma face to face. Should I take the path of least resistance and do the same under-stimulating questionably effective treatment that the clinician before me had been doing for the previous three weeks? Or do I progress into the realm of the uncommon and uncomfortable, teasing out the proprioceptive and neuromuscular adaptations this client needs so dearly?
Documentation is a drag. No way around it. But as we collectively attempt to improve the reputation and clinical outcomes of home health patients, it is essential to continue placing patient needs above our own. Computer systems all have their limitations, but they should never limit what we do for our clients.
Fortunately in this case I fought the urge to take the path of least resistance. Despite knowing the documentation was going to be a bear, I knew what my patient needed most in that moment. With my resolve restored I grabbed the blue painters tape from the supply bag and laid out a makeshift dot matrix on my clients living room floor and continued with what turned into a breakthrough session.
To steal a phrase from Neil Maltby “Be more human. Less robot.”
Written by: Stephen Stockhausen