Is profit the best KPI in health care? Is volume of patients in your clinic a good measure of your business’ mission? Is there a better “healthcare” KPI?
A KPI is a Key Performance Indicator and the purpose for these in your clinic are multiple. They are objectives that produce data points that are used to track objective items. They are meant to be representative of the work you are doing, so that an outside source (typically your manager or owner) can know what you are doing day-to-day. In application: They are meant to signal to you, the clinician, what is important to your manager. It also signals to the manager what is important to the company, or the share holders, or the owner.
KPIs had their modern start in the 1920s with the DuPont Table, and in the 1930s with the Tableau de Bord or Balanced Scorecard. Since then companies far and wide, from Google with their “OKRs” to your private practice PT company, use them to track data, align values and drive behavior.
KPIs are data. These pieces of data (often in dollars, or visits per month, or number of referrals, or units per visit, or whatever your company deems important) are used as a communication tool. “The signaling of importance.” Aka: how you are going to be judged as successful… because this is how they are judging themselves as successful.
If a KPI signals “Importance” then isn’t that what you’re supposed to be focused on? So again, is cash the best KPI? Should you as a clinician be focused on cash during each interaction? Cash certainly is measurable. Are visits to your clinic a good indicator of how awesome your clinic is? Visits certainly are measurable.
Let’s back up and check some things. Unpack it. The purpose of any business is simply to make money. *Broad strokes comment.* You get that. In each company the mission, values, services, products, location, organization charts, etc, are different, but each one, including “non-profits,” need to pull money in.
So you are tracking a thing that is not unique to your business. In this case: Physical Therapist delivered healthcare. You are tracking money, just like the auto dealership, the furniture store, the massage parlor, the hotpack* supplier. In health care we are in a unique spot, in that our patients don’t choose us, as in, “I want to injure myself and do rehab.” We are providing a needed service that is medically necessary.
Shouldn’t you be tracking an item distinct to your service? Does the focus on money just drive you and your decisions to act and behave like other industries, since KPIs are used to rudder the boat? Ok, money is good, it can help you buy the squat rack* and fund your life. As a focus on how well you are providing skilled care, however, money can easily (see profit motive) turn your decisions away from that of the patient and towards that of the “data reward.”
The owner gives praise to manager for the “productivity,” the manager give the clinician praise for the “productivity”… humans are praise-seeking… you want some more of that praise, then you behave in a way that gets you more praise. Easy math.
WIKI: In economics, the profit motive is the motivation of firms that operate so as to maximize their profits. Mainstream microeconomic theory posits that the ultimate goal of a business is to make money. Stated differently, the reason for a business’s existence is to turn a profit. The profit motive is a key tenet of rational choice theory, or the theory that economic agentstend to pursue what is in their own best interests. Accordingly, businesses seek to benefit themselves and/or their shareholders by maximizing profits.https://en.wikipedia.org/wiki/Profit_motive
The majority of criticisms against the profit motive center on the idea that profits should not supersede the needs of people.https://en.wikipedia.org/wiki/Profit_motive
How about visits to a clinic? This makes since as a KPI, right? It’s the same signaling as a restaurant with a line around the block right? I’ll argue a strong “No” that this does not clearly indicate a good clinic, good clinician, good outcomes. It does, in fact, measure how many visits there were to a clinic! While “busy” has some proxy and overlap to quality of care, or “being the best around”, this might alternatively indicate low competition, good marketing, good location, or… business practices that allow, seek out and encourage the high visit rate. Perhaps double/triple booking is financially encouraged, or awards are given, etc. This would influence (naturally) the behavior of the humans working in this site.
Tons of visits could mean a lot of things. Low visits could mean a lot of things as well. Perhaps low visits means: bad location, poor service, grumpy staff, bad outcomes or high market competition. However, the low visit count KPI could exist in an environment of great one on one care with ethical POCs, discharge and referral practices. What about truthful communication about a condition that will heal mostly on it’s own and does not need 3x/wk visits for 8 weeks. Just 4 follow-ups over the next 8 weeks will do just fine. Is there a KPI for that?
Everything in a free economy relies on trust and honesty. You, as a patient, come to me in this hypothetical: You trust that I need to see you 3 times a week and that I should be rubbing your patella. It may just be that I am rubbing your patella and seeing you 3x/week because they enhance my KPIs and that good KPIs are starting to be where my rewards are coming from. I get more praise more often when I meet my KPIs vs when I truly exhibit honest recommendations. Humans are easily swayed in this manner, and I, the clinician, am a human.
See the link to this study in Archives of Rehabilitation Research and Clinical Translation from February 2019: Are productivity goals in rehabilitation practice associated with unethical behaviors? *Short answer: “A positive correlation existed between expected productivity rate and rate of unethical behaviors observed (rs=.225, p<.0001). Amounts of organizational emphases on ethical practice (rs=-.509, p<.0001) and evidence-based practice (rs=-.492, p<.0001) were negatively correlated with total observed unethical behavior.”
Now you’re the clinician: What do your KPIs look like when only see a patient for 30 minutes, maybe not again for a week if you find this professionally appropriate. Maybe you DC them when they are 80% better and can be independent at the gym. They can call you and tell you when they are back to 100% if they like, or make a follow-up, but they no longer need your medical supervision to continue with their progress. No KPI high-fives on that one. But you might get a high-five from the patient… which is nice but not guaranteed.
Could things change? I can easily print out a sheet and write on it:
- Clinic KPIs:
- Address patient goals every visit
- Progress towards patient goals
- Ethical Decision Making
- Efficient use of patient time
- Effective Dose, Frequency, Duration
- Improve patient independence
You get the idea… I just jotted down a few things that are not Money or Visits but that seem important to the professional physical therapist and the patient. Perhaps a clinic focused on how the patient responds to treatment, or how the patient views the value of rehab. Guess what? These are not easily measurable. So it turns into more of a “mission statement” than a measurable data point.
FOTO sells that they can track some of these things, like “We are 85% good at treating backs!” or something similar. That KPI, however, tries to fit people in to the FOTO questionaire, assumes accurate data input by the patient (cognitive assumption) or could lead to you advertising/marketing and seeking out easy cases with good quick outcomes, could it not? What about a KPI on just “patient satisfaction?” That can lead to pandering and down a slippery slope as well. See Death by Patient Satisfaction in the ER by ER Doc Rada Jones, MD.
You’ve got to dig down and do the work and sometimes there’s no KPI for that. Can you keep the needs of the people at the forefront? It’s hard to reward the fact that you spent last night looking at the best way to load your patient in a safe manner that creates a physiologic and quality of life change for them this week. That you spent time discussing their case, looking over their plan, talking directly with them instead of checking boxes in your EMR. You progressed their flowsheet exercises to the next appropriate movement. Those things may go un-noticed in the data world, but they are the true “Keys” of a good clinic and clinician. There’s no KPI for caring enough to push your patients and guiding them well. There’s no KPI for spending time listening (there’s not a CPT Code for listening either, yet this drives outcomes). There’s no KPI for QTI (Quality Therapist Interaction).
When I posted about QTI on Twitter, Jerry Durham replied and he proposed Completion of Plan Of Care as a KPI. This may encompass many of the things that are important.
- It focuses the PT on the patient. Encourages professional relationship building and therapeutic alliance.
- It encourages making an appropriate POC (frequency, duration). A completed POC of 5 visits is the KPI. You own that.
- It encourages the PT to use Evidence Based Practice since a good outcome and a functional happy patient is the goal. Hot packs and Estim for 2 weeks doesn’t complete any plan.
- It keeps the staff focused on visits that can’t be missed, because if the POC is correct, those visits are needed.
- It keeps a time frame in mind. We need to get this goal accomplished by this time.
Maybe that’s a place to look… and it can have a number to it (data!) and you need numbers to determine if you are productive or not.
The idea that productivity is a concept in health care management is hotly debated, mostly from the clinician side. The administrative side (removed from patient interaction and the meat of the profession) is fine with “productivity.” Check out It’s time to ban productivity from medicine by Robert Centor, MD on KevinMD.com.
Doing right by the patient is the focus. KPIs measure what they measure. The KPI might represent the outcome of good care, but again- the KPI must signal what is meaningful and thereby drive behavior.
Healthcare is certainly a business, and people make money in this space, but I’ll argue that the best outcome (both monetary and satisfaction) are made from focusing on the patient and their true needs from our service.
While this might seem like a rant on money, and you already knew that incentives are carrots on a stick, but the take-away is really meant to be a cue to you, your manager, your company, our industry… that the focus needs to be on excellent patient care.
Now, go make a KPI for that.
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