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In healthcare,
clinicians often feel like they're stuck
in the middle.
Call between doing the right thing for
patients
And hitting numbers,
the business needs to survive.
But what if those two goals were never
supposed to compete?
What if they weren't supposed to be
separate?
Today's guest has spent a career helping
rehab teams and clinicians stop fighting
the business side of healthcare and start
understanding it.
She's trained thousands of clinicians
across the country to translate
complicated clinical challenges...
into practical systems that actually work
in real clinics it's got to be real
uh she's part speech language pathologist
part pretend pt and ot but we're all
cousins part educator and part strategy
leader let's welcome back to the show
katie holterman katie welcome back to the
program thank you uh what's nice in theory
may not be practical and what's practical
may not feel nice so the tensions
that clinicians feel between quality care
and productivity expectations,
they're real.
So clinicians often say they feel like
business pressures conflict with patient
care.
Let's start with where.
Where does that tension actually come
from?
I think the tension comes from clinicians
not understanding that business is
business and that it's okay to know that
you are actually working for a business,
that it's okay to know that money makes
the world go round, right?
And it has to be a component of
the conversation,
but that as long as that conversation is
led with clinical eyes and clinical words,
the fiscal piece will follow it and it
just will be a good thing.
I mean, this is why
nursery rhymes or fairy tales or fairy
tales because it's a story that teaches a
lesson.
This is why schoolhouse rocks.
This is how a bill becomes a bill.
You can be mad when things aren't your
way, but when you begin to understand,
hey, there's a process.
If you want the outcome,
let's go back to the beginning and see
how this thing changes.
I think it's probably on the syllabus.
In fact, I know it is.
It must be mentioned somewhere,
but it's probably different
program to program in terms of, hey,
you're going into healthcare.
And then there's like seven subtitles
layer.
Healthcare is a business.
It's probably one of the businesses.
There are others like it where it's driven
by this mission,
but it's still a business.
If you'd like to get paid to do
this,
there needs to be some sort of financial
exchange in order to keep the lights on
and pay for the people involved.
who actually provide the care.
Larry Benz in a recent episode even said
in a health care organization,
your assets wear shoes.
Your assets are the people.
I know you might have machines or
anything,
but even if you're a hospital with MRI
machines and helicopters and ambulances,
really your most important asset, nothing,
nothing moves unless you have people.
Exactly.
And here's the problem.
I think the core of it before the
person becomes the employee in
PT, OT and speech,
they're the student and the student isn't
taught business.
They're not taught that their product is
what they're selling or they're not taught
the financial aspect of it.
So we go into this business thinking,
okay, well,
everything else is going to make the
money.
We're just going to treat.
Right.
You are a service, right?
Ritz-Carlton doesn't really sell beds.
They sell the experience,
everything from the moment you pull up to
when you leave,
if there's a mint on the pillow.
And I've heard of healthcare organizations
bringing in, quite literally,
the Ritz-Carlton's
sort of management or experience school to
understand
you're providing experience, right?
So your framework sort of starts with
defining non-negotiables.
And I like those because as creative or
as free as we can be in how
we treat, right?
There should be some non-negotiables.
In order to be really creative,
to think outside the box,
there's got to be a box.
So your non-negotiables are a box.
And I like those things.
Exactly.
What does that look like in a real
clinic, your non-negotiables?
Yeah,
so I think of these as like clinical
guardrails, right?
What is that box that you're not going
to go out of,
but you can play within it?
So what is the max number of patients
or people per therapist?
What does that look like?
And when it starts to go outside that
box or outside that guardrail,
then you know you're getting a little bit
into more of that
sticky place of is that really a business
motivated decision versus your clinical
guardrail of this is patient care.
So that's an example of just I think
staffing is a really good one.
What does your staffing look like?
And is it that you're trying to have
X number of staff for, you know,
this day versus this day?
And does that make clinical sense because
of the patient makeup that you have in
that day?
So clinical guardrails, I think,
are really important from a documentation
standpoint.
You know,
what is your clinical guardrail there?
And then obviously from a billing
standpoint, you know, from CPT codes,
you know, what does that look like?
Of course,
I come at everything from the lens of
the guy who used to work at a
radio station,
but there's so many parallels,
and we were taught the difference between
policy and law.
Now, first of all,
you can't violate the law.
You can't do it.
I mean, you can, and people do,
but you're going to get caught.
Just pretend like you're going to get
caught.
Don't do it, right?
So there was the FCC.
Don't break any of their rules.
I don't care what you're doing.
Don't do it.
Then there was policy and that's set by
the company.
We don't do these things.
And that's like, Hey,
if you want to work here,
you can't break these laws.
We, these rules, sorry, not laws rules.
Cause we'll fire you for that.
That's outside of our bounds.
And the funny part was in radio,
it's much like it was so it's funny
to come to healthcare and be like,
Oh my gosh, this is,
and I'm sure it's other, you know,
professions too.
Everybody on the air, we made the thing.
We made the funny commercials and we made
the whatever.
We picked the music and we talked, right?
We were the clinicians.
We were the product.
And we would look at sales and management
as sort of always wanting to butt heads.
And the minute I sort of realized that
without them, we can't do what we do.
And without us, they can't do.
We are in the same boat.
We are tied together.
So instead,
I sort of pulled a Bruce Lee move
and it was only because I had smart
bosses around me.
be water.
The goal is to get along,
to go along,
but I made sure to sort of hold
fast to, well,
I understand why you're trying to do that,
but that's asking me to violate some of
the things that keep our brand a brand.
Which if we do an exception now,
what's the stop of six months from now
for doing that?
If we eventually do it now,
no one's listening and now you can't sell
anything.
And I feel like it's the same for
clinicians.
It's like, well, if we make exceptions,
I understand why you're telling me that,
but I can't do it because I've also
got a license.
I didn't have a license in broadcasting.
You didn't have to have one.
You lose that in healthcare, you're done.
So that should be also be your guiding
light.
Yeah.
And also, you know, the,
when you start making the exceptions,
it's easy to lose sight of when that
exception then becomes the norm, right?
The slippery slope idea, right?
Yeah.
You make that exception once,
then you make it again.
And then it's, well, was it really,
was that really within our clinical
guardrail?
Right, right, right.
Did I make that up?
So it's important to really keep and take
hold of that.
Right.
So this,
I think everything I just sort of heard
or a lot of what I just heard
sounds like,
understanding what you do and where you
fit.
And this is understanding the physics of
the environment.
Yes.
Given a blank check and all the time
in the world,
you would treat people differently.
But we do not have a blank check
and unlimited time in this environment.
That just is not.
So we have to understanding the other
side, management,
if you're a clinician or clinicians,
if you're management,
because sometimes management are former
clinicians like yourself.
Sometimes you're not.
So sometimes more understanding is
typically always better, right?
Like understanding is either confirming
what you already knew or teaching you
something new.
Exactly.
And you, you,
I think that that understanding and it
goes a long way because then you can
speak the language for the other person
too.
Like when you're all on the same page,
it just makes the, the,
it makes everything easier.
And so that starts with communication,
clear, clear communication.
Yep.
You,
you say if something matters clinically,
it should be measured.
Yes.
What are the most important metrics then
that clinics should actually track?
Because in twenty twenty six and beyond,
believe me,
we could track the list of things we
can track is only listen.
You can actually hear it getting longer as
we speak.
But what are the most important metrics?
Because we can't have a million KPIs.
It makes them not key.
That's what K and KPI means, right?
So what are what are the most important
metrics that you think clinics should
actually track?
Yeah, well, before I answer that,
I think what you just said is so
important that it deserves to be kind of
said again.
Everything can't be important.
Can't be.
And if you're measuring it,
for goodness sake,
ensure that there's like a compelling and
real story behind it, right?
It has to matter.
So what matters for clinical care and why?
And the why part is the important part.
because then that will help you figure
out, is it really important to measure?
So for example, frequency, right?
How frequent are we seeing patients per
week?
That's a metric that everybody seems to
want to measure.
Are we seeing them three times a week?
Is that appropriate?
Well, why?
Why is that appropriate?
It may be appropriate for one type of
patient and not for another.
So it really doesn't make sense and we
can kind of throw that away if we
don't have the why behind it.
Number of visits, right?
That's gonna be something that people are
going to measure.
But again, why?
What's the magic number and do we have
a story behind that that gives us reason
as to why we need to measure that?
And then outcomes.
Right.
In this day and age,
we're moving towards value based care.
Actually, scratch that.
We are in value based care.
And so outcomes are of utmost importance.
But if we don't if we're just measuring
outcomes because we think we're supposed
to measure this assessment,
this this this measure that CMS says we
have to measure.
Okay,
that does make sense because it fits into
the value-based care model.
But at the heart of it,
what's going to say that your clinic is
the best clinic out there?
Is it, you know,
I come from the geriatric world.
So a lot of times we would measure,
you know, something around falls.
We would measure, you know,
is the patient at risk for falling?
Okay.
What's the number of times they've fallen
in the year?
That's one measure that we can, you know,
that that might matter.
And then insurance companies may pay us
more if
their patient is not falling as much,
if their patient is not at risk for
falling.
But wouldn't it be great if we had
a better measure of, well,
what's the number of times that they
engaged in something or didn't engage in
something because they had a fear of
falling or didn't have a fear of falling?
And it's because I had PT and it
made a difference.
Well,
now we have a domino effect of all
of the things that that can potentially
impact.
including, again,
payment from insurance companies.
So I think there's a number of things
that we need to look at measuring.
But more importantly,
why are we measuring it?
What is the story behind it?
What is the purpose?
And I was taught that early in my
career.
It doesn't really matter what my career
is.
The advice was still good.
Number one, a great boss said, she said,
figure,
understand at least the basics of every
job in this company.
even if you're not going to do it.
So go out, ask, volunteer.
I came in as a broadcaster,
but I was going out when I didn't
have to to help set up events because
I was like,
I'm going to need to send these people
out.
I want to know what I'm sending them
to when it's raining or snowing or when
I give them no notice.
When someone turns to me and says, well,
it takes four hours to do that.
I'm like, oh,
we can do that in an hour and
a half.
Or I know I'm sending you to something
awful.
I'm going to give you more help.
But understanding what the actual job
entails why you're doing it.
And then at some point that why might
have changed and now you don't need to
do that anymore.
So why are we doing it?
There seems to be no reason.
I guess we can discontinue that.
So understanding the why is everything
I've heard so far.
Yes, a hundred percent.
Yeah.
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I mean, even EMRs,
they have access to so many things.
So you can measure.
But if you're not asking upstream what
you're looking for or what you want to
measure,
you're not going to get that good data
downstream.
So let's move forward in this timeline.
Once metrics exist,
the real challenge now is getting
clinicians to care about them.
This just feels like it's a feedback loop.
How do you suggest we create buy-in or
what have you seen work,
not only in theory, but in practice,
in reality?
make it visible,
make the frontline clinician be able to
see what those metrics are.
Again,
they know the metric and they know the
why behind it.
Once you get past that,
it's kind of an easy slope to kind
of glide down.
But if they don't see it,
then they're not going to have it
constantly in their workflow,
in their reminder, in their daily life.
But making it visible is one thing.
How are they interpreting it and are they
interpreting the metric correctly?
So make it visible,
make it a part of conversation so that
they understand what the metric is telling
them and again, what that story is.
I think who who talks about the metrics
and what they say about them are
as important as the metrics themselves.
So in other words,
clinic owner talks about a metric that
they're, you know, let's just say it's,
you know, revenue per day.
A clinic owner talking about that and just
saying, okay, our revenue per day is this,
and here's the number and walks away.
Frontline clinician does not care about
that.
It's tone deaf.
But if you talk about it in the
way of here's our revenue per day,
and here's how we got to that number.
And it was X number of units.
And this is the CPT code that you
used.
And let's talk about your documentation.
And does your documentation reflect what
you did?
Is that the right CPT code for what
you did?
And if it is, great, perfect.
If it's not,
maybe we need to change that.
That's a clinical discussion.
That turns that whole clinician's mind
frame,
mindset from here's a number and walk
away.
Here's what you did.
I'd love to know more about it.
Let's have a conversation about that.
But the more they see that in front
of their face and hear that information,
at least that's a conversation they're
willing to have them i think yeah
clinicians are not stupid i mean they can
understand this the thing is if but but
you can't understand something that hasn't
been put in front of you or you're
not discussed or it's it's it's been
hidden from you this is why revenue per
day in your clinic matters and you're like
why so you can buy another boat it's
like no because if we if this stays
low for too long we close
And then we provide no care to anyone.
Or if we can figure out a way
to clinically improve care or find more
people to help, we raise that number.
We can hire another clinician or we can
expand to another thing or we can give
you a raise.
I don't think clinicians want,
for the most part,
to produce more
just to get a raise,
and I don't think you should.
But if you understand that doing a few
more butterfly, you know,
the butterfly flaps its wings, right?
The butterfly effect, what that does,
the tail shouldn't wag the dog,
but the dog should wag the tail.
Like, that's why we got into this.
It's really funny,
especially in healthcare.
I say we have the Peace Corps gene.
Many people, and rightfully so,
would like to be paid more.
But they would also like to give a
lot of things away for free or included.
And those two things don't math.
Those two things,
they don't work together.
I'd love to see how that works.
But you've said dashboards and scorecards
matter.
I sort of like that second one too.
Only if people actually see them, right?
An invisible scorecard that I'm getting
graded on.
Even in higher education,
there's a rubric.
I know how much percent of my grade
or anything.
A lot of times I think you're right
where it's not visible.
So what is good visibility look like in
the clinic?
Because I imagine too much might be
paralyzing.
Absolutely.
Yeah.
I think it's this balance, right?
Where you don't want so many numbers
coming at people and so many different
scorecards and different dashboards and,
you know,
different numbers that mean different
things in different ways because then it
becomes white noise.
But invisible metrics
die quick,
make the actual metric die even quicker.
So it's a balance.
I think that scorecards are important from
how the clinician is doing themselves.
Everybody wants to do well.
Nobody gets into this field to say,
I want to be a really can I
swear on here?
Sure.
I want to be a really shitty clinician.
No one says that.
People want to take pride in the work
that they do.
So a scorecard is a great way to
do that.
And this goes back to outcomes.
Nobody wants to go in and being like,
I'm gonna give mediocre therapy today.
And maybe this knee injury is gonna get
better by itself.
Maybe I'm gonna help it a little bit.
No,
people want their patients to walk out the
door and go, oh my gosh,
Katie did a fantastic job.
I'm gonna refer her to all of my
friends.
that makes us feel good.
And so that kind of a scorecard and
visibility from our outcomes perspective
and our cash business perspective,
that all paints the picture of how good
of a clinician you are at the end
of the day.
With a good scorecard,
imagine we both understand what the number
means and how it changes.
If you're giving me a C and I'm
like,
but I don't know how I make the
C a B, that's not fair.
And then understanding how it lines up
with the big picture.
How does this move the entire boat
forward?
So this is just an alignment of good
expectations.
I mean, most things that...
you know,
devolve into stress or disagreement.
If you rewind, it's because of missed.
I said that,
but that's not what I meant.
Or I you said that,
but I heard this or I don't understand.
Sometimes it is as simple as a simple
but not easy as understanding what those
expectations really are and making sure
they're aligned.
Yeah, absolutely.
And words matter.
The way you say things and explain things
do matter.
And I'm a big believer in that.
I think because I'm an SLP,
I definitely always go with the, you know,
choose your words carefully on how you
explain things.
Correct.
Yeah.
I said that,
but this is what I heard or I
thought that.
Right.
Is what this meant.
Right.
Katie,
your hot take is that it's okay to
give up a little clinical autonomy.
What do you mean by that?
I like that.
Sounds scandalous.
Gosh,
you people hate to hear this usually.
If I had a dime for every time
I heard,
you can't tell me I can only do
this assessment.
My clinical judgment is this.
I'd be a very rich person.
Yeah.
And I don't mean this that, you know,
yes,
we're taking away all clinical autonomy.
No one should think for themselves.
That's not what I mean.
But standardization is what makes things
flow easily.
It's what helps produce these numbers that
we can actually measure.
and produces scorecards that we can talk
about.
So it is okay to have some standardization
in place,
whether that is everybody has to use this
assessment so that we level the playing
field on measurement.
You can use other assessments and that's
where your clinical autonomy comes in.
But if you want to set a standard
for your clinic to say, OK,
but everybody has to at least at a
minimum use X, Y, Z, that's OK.
It's not taking away anybody's clinical
judgment.
It's not saying you're going to be a
cookie cutter PT.
It's saying I'm going to make sure that
at the very minimum,
this is the standardization of workflow.
And it produces a better product.
Understood.
Yeah.
All right.
I can see that.
Last thing I'll ask before we do a
parting shot is where do leaders usually
lose their team in this sort of
discussion?
Right.
So we just I feel like we just
talked about.
metrics,
but brought it back to words and
understanding.
So where in this process do leaders
usually lose their team in this?
Two places.
When they don't talk about the why and
when they
only have that business hat on and forget
that that frontline clinician doesn't give
a rat's ass about the business and i
don't mean that that they you know we've
talked about they need to give them you
know they need to care about the business
they need to understand it
But at the end of the day,
they want to know what is in it
for them as a clinician and why we
are doing what we're doing.
So like, for example,
good documentation protects revenue.
That's just a fact.
But talking to the clinician about how
good documentation protects their license
and keeps them out of jail is actually
going to help.
It's going to do the but what about
me factor.
And remembering that clinicians aren't
taught about business.
So, you know,
we need to talk about it frequently
because they aren't,
it's not in their daily routine.
thought process.
But if we talk to them again as
a clinician and how it relates to clinical
care,
it's going to take that clinician and that
business a long way.
Yeah, words matter from an SLP.
Parting Shot is brought to you by our
friends at US Physical Therapy.
Today's show is brought to you by USPH,
partners with clinic owners who want to
grow without losing their identity.
You stay local and in control while
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Learn more at usphpartnership.com or find
out at usph.com.
I'm going to pitch you a question for
the parting shot instead of letting you or
making you sort of go from scratch.
Here's your parting shot question.
If rehabilitation is going to survive,
right, as a whole, PTOT speech,
whatever you want to call it,
rehab is going to survive,
the shift that we're already in to
value-based care,
what's one mindset the clinicians need to
change right now?
Gosh, your parting shots always kill me.
I would say that without good clinical
care and without showing evidence of what
that looks like,
there's no point in actually even
providing it.
So making sure that you, you know,
showing the evidence behind showing the
work.
Like I, I have a, a.
Fifteen year old son who is complaining to
me every day that he has to show
his work and in his, you know,
homework that he's doing for math and for
LA and all that.
Mom,
why do I have to show my work?
Because at the end of the day,
that's what you're getting graded on.
It's not the output.
It's actually the work that you've put in.
And so outcomes are the same way.
It's a great analogy.
Uh, Katie Holderman,
thanks for coming on here and talking
about this.
Much appreciated.
Absolutely.
Thanks for having me.
That's it for this one.
We're just getting warmed up.
Smash follow,
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And legally, none of this was advice.
It's for entertainment purposes only.
See, Keith, we read the script.
Happy now.